上腸間膜動脈灌流障害を伴う急性大動脈解離に対するperfusion-first strategy

Perfusion-first Strategy for Acute Aortic Dissection with Superior Mesenteric Artery Malperfusion

急性大動脈解離（AAD）は，緊急手術を要する致死的疾患である1）．中でも，上腸間膜動脈（SMA）の灌流障害（MMP）は広範な腸管壊死を引き起こし，きわめて予後不良な合併症である2）．近年のメタアナリシスでは，院内死亡率は36％に達することが示された3）．

Background：Superior mesenteric artery （SMA） malperfusion in acute aortic dissection （AAD） is a highly lethal complication with no established treatment strategy. We introduced a “perfusion-first strategy,” prioritizing SMA revascularization via laparotomy for patients with preoperative computed tomography （CT） evidence of SMA obstruction.

Methods：Our strategy involves an initial laparotomy for direct visual assessment of intestinal ischemia. After identifying the occluded segment of the SMA with vascular ultrasound, a bypass is created to the distal SMA using a heparin-coated expanded polytetrafluo roethylene （ePTFE） graft. Initial reperfusion is established via a side branch of the extracorporeal circulation circuit from the femoral artery. This is followed by a median sternotomy for central aortic repair. Finally, the SMA bypass graft is anastomosed to the central aortic graft to complete the revascularization.

Results：Between April 2024 and May 2025, this strategy was performed on six consecutive patients. All six patients survived to discharge without requiring bowel resection. Postoperative CT scans confirmed the patency of all SMA bypass grafts.

Conclusion：Our perfusion-first strategy, a single-stage hybrid approach, was shown to be a safe and effective treatment for AAD complicated by SMA malperfusion in this initial series. This approach allows for accurate assessment of intestinal ischemia and reliable revascularization while avoiding the risks of delaying central aortic repair. It represents a promising new therapeutic option for this fatal condition.