Ischemia-reperfusion injury central in early mortality after thoracic endovascular aortic repair (TEVAR)

Jan 27th – 75% of in-hospital deaths after TEVAR for acute complicated type B aortic dissections were due to pre-existing organ malperfusion and ischemia reperfusion injury.

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Image: CC/Heilman

1. 75% of in-hospital deaths after TEVAR were due to pre-existing organ malperfusion and ischemia reperfusion injury.

2. Deaths may be prevented by removing compromised organs before performing TEVAR and reintroducing their toxic metabolites into the rest of the body’s circulation.

While TEVAR saves lives of patients with acute complicated type B aortic dissections by restoring blood flow to underperfused organs, this restoration of flow is also paradoxically responsible for a majority of deaths after the procedure. Severely malperfused organs produce metabolic toxins that are normally sequestered away from the rest of the body. TEVAR reopens the floodgates for these toxins to be absorbed systemically, where they can precipitate multiple organ failure in the rest of the body. This observation underscores the importance of minimizing ischemic damage to organs but also, if this is not feasible, of removing critically injured organs to maximize patients’ likelihood of survival.

Click to read the study in The Journal of Cardiothoracic Surgery

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Image: CC/Heilman

1. 75% of in-hospital deaths after TEVAR were due to pre-existing organ malperfusion and ischemia reperfusion injury.

2. Deaths may be prevented by removing compromised organs before performing TEVAR, which would reintroduce them and their toxic metabolites into the rest of the body’s circulation.

This [retrospective] study reviewed data from 2004-2010 at the Chinese PLA General Hospital in Beijing, China, during which period a total of 26 patients with acute complicated type B aortic dissection underwent TEVAR. Four in-hospital deaths occurred, three of which were attributed to pre-existing organ malperfusion and ischemia-reperfusion injury. All three of these deaths were preceded by multiple indicators of severe end-organ malperfusion.

Further reading:

1.  Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection.

2. Complicated acute Type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection.

3. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy.

In sum: While TEVAR saves lives of patients with type B dissections by restoring blood flow to underperfused organs, this restoration of flow is also paradoxically responsible for a majority of deaths after the procedure. Severely malperfused organs produce metabolic toxins that are normally sequestered away from the rest of the body. TEVAR opens the floodgates for these toxins to be absorbed systemically, where they can precipitate multiple organ failure in the rest of the body. This observation underscores the importance of minimizing ischemic damage to organs but also, if this is not feasible, of removing critically injured organs to maximize patients’ likelihood of survival.

Click to read the study in The Journal of Cardiothoracic Surgery

By [GS] and [AH]

More from this author: An argument against hospital admission for heart failure, Common therapeutic target for heart failure, hypertension, and chronic kidney disease: the carotid body and sympathetic activation.

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1f636eeGina Siddiqui: Gina is a 3rd year M.D. candidate at the University of Pennsylvania.

 

 

 

 

Allen Ho: Allen is a 4th year M.D. candidate at Harvard Medical School.

 

 

 

 

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