When is laparotomy for mesenteric ischemia after aortic dissection futile?

BACKGROUND

Tissue necrosis from persistent mesenteric ischemia after aortic dissection may progress to sepsis and death without emergent laparotomy. However, the signs of mesenteric necrosis are common in patients experiencing non-survivable multisystem failure after aortic catastrophe. No study has yet examined when and whether laparotomy offers a chance for meaningful survival in these patients.

METHODS

A total of 145 patients treated for acute Type A or Type B aortic dissection with mesenteric ischemia were identified from a single institution from 2006 to 2022. Of those, 29 underwent laparotomy all for compelling clinical indication. Detailed clinical characteristics were studied with respect to short and long-term outcomes in these patients.

RESULTS

Among laparotomy patients, 45% (13/29) survived to discharge compared to 71% (103/145) of all mesenteric malperfusion patients. Serum lactate and arterial pH were both very strongly associated with survival after laparotomy. Among survivors and non-survivors, mean lactate prior to laparotomy was 6.3 mmol/L vs 13.4 mmol/L (p=0.024) and pH was 7.39 vs 7.20 (p<0.001). In particular, lactate over 8 mmol/L (OR [95%CI] = 16.5 [2.0-192], p=0.003) and pH under 7.30 (OR [95%CI] = 14.4 [1.87-128], p=0.003) were highly predictive of mortality. Survival to discharge after laparotomy for patients with both severe lactatemia and severe acidosis (defined above) was 9% (1/11) compared to 90% (9/10) for patients with neither severe lactatemia nor acidosis.

CONCLUSIONS

The degree of lactic acidosis can very effectively identify patients for whom laparotomy is futile and those for whom it is not after aortic dissection with mesenteric ischemia.

Informations de copyright

Copyright © 2024. Published by Elsevier Inc.