J Extra Corpor Technol 2025, 57, 119--122 Ó The Author( s), published by EDP Sciences, 2025 https:// doi. org / 10.1051 / ject / 2025015
Available online at: ject. edpsciences. org
REVIEW ARTICLE
Peripheral veno-arterial extracorporeal membrane oxygenation as a bridge to surgery in type A aortic dissection: a review on strategic approach to managing malperfusion syndrome
Ignazio Condello( PhD) *
Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Anthea Hospital, University of Insubria Varese, Via Camillo Rosalba 35 / 37, 70124 Bari, Italy Received 6 February 2025, Accepted 27 April 2025
Abstract – Background: Acute Type A aortic dissection( ATAAD) is a critical cardiovascular emergency characterized by high mortality rates and complex management challenges. The presence of a tear in the ascending aorta often extends into the aortic arch and descending thoracic aorta, leading to malperfusion syndrome, a severe condition resulting from obstructed blood flow to vital organs. Despite the high risks associated with ATAAD, the use of Peripheral Veno-Arterial( VA), Extracorporeal Membrane Oxygenation( ECMO) remains controversial. This intervention aims to maintain systemic circulation and organ perfusion, potentially stabilizing patients prior to surgical repair. Materials and methods: A narrative review of the literature was conducted through a comprehensive search of PubMed and Embase databases, covering the period from January 2000 to March 2025. Keywords included“ ECMO”,“ Type A Aortic Dissection”,“ malperfusion”, and“ bridge to surgery”, among others. Although this is a narrative review, the methodology was guided by the PRISMA guidelines to ensure transparency and reproducibility in the selection and reporting of the included studies. Results: Ten relevant articles were identified, including observational studies, case series, and reviews. This narrative review presents the role of peripheral VA ECMO in managing ATAAD, focusing on the timing of ECMO initiation and its implications for patient outcomes. The approach emphasizes rapid deployment following confirmation that the iliac and femoral arteries are free from dissection involvement, ensuring safe cannulation and effective circulatory support. The discussion also explores ECMO’ s role as a bridge to surgery, detailing its impact on preventing malperfusion to critical organs such as the brain, kidneys, and splanchnic organs. Conclusion: While VA ECMO offers a potential lifeline for patients with severe ATAAD, its application must be carefully considered within an integrated treatment strategy. The ongoing debate and emerging research underscore the need for further studies to define clear guidelines and optimize ECMO’ s use in this high-risk patient population. The balance between preventing malperfusion and managing increased myocardial workload presents a complex clinical challenge, necessitating continued investigation and dialogue within the medical community.
Key words: Acute type A aortic dissection, Malperfusion syndrome, ECMO, Emergency, Cardiovascular care, Patient survival.
Background
Acute Type A aortic dissection( ATAAD) represents one of the most severe cardiovascular emergencies due to its high mortality rate and complex management challenges. This condition involves a tear in the ascending aorta, which can extend to the aortic arch and descending thoracic aorta, creating a false lumen that compromises blood flow and can lead to catastrophic outcomes, including malperfusion syndrome. Malperfusion syndrome, a critical complication of ATAAD, results when the dissection flap obstructs blood flow to major arterial branches, leading to ischemia of vital organs. According to a nationwide
* Corresponding author: ignicondello @ hotmail. it analysis by Goel et al., preoperative malperfusion occurs in approximately 27.7 % of ATAAD cases, significantly increasing operative mortality rates. The study underscores that malperfusion most frequently affects the extremities, kidneys, and brain, and varies in mortality impact based on the region affected [ 1 ]. For instance, coronary and mesenteric malperfusions are associated with the highest mortality risks. Despite the acute risks associated with ATAAD and its complications, the use of Peripheral Veno-Arterial( VA) Extracorporeal Membrane Oxygenation( ECMO) remains a debated intervention. VA ECMO serves to maintain systemic circulation and vital organ perfusion, potentially stabilizing patients prior to surgical repair. This approach could be useful for peripheral centers that do not have cardiac surgery programs, and the expected transfer
This is an Open Access article distributed under the terms of the Creative Commons Attribution License( https:// creativecommons. org / licenses / by / 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.