This case report described a novel strategy for managing LEM in type A aortic dissection by providing temporary perfusion during dissection repair, minimizing ischemic complications.

Figure 1. (a) Axial contrast-enhanced CT scan of the ascending aorta showing type A dissection. (b) Coronal CT showing reduced true lumen area in the descending aorta. (c) Axial CT at the iliac bifurcation showing false lumen dominance. (d) Contrast in left femoral artery (absent in the right). (e) Schematic diagram of femoral and subclavian cannulation with 10F catheter.
CT: Computed tomography.

Surgical procedure
Arterial cannulation was established in the right subclavian artery for cerebral perfusion and in the right femoral artery for retrograde true lumen perfusion. A 10F catheter was connected to the femoral artery cannulation line, with catheterization distal to the cannulation site to provide distal perfusion to the right lower extremity (Figure 1e). This enabled simultaneous retrograde flow from femoral cannulation and antegrade flow via the 10F catheter. After restoring extremity perfusion, a Bentall procedure with a no. 21 mechanical valved conduit and hemiarch replacement were performed after median sternotomy. Cardiopulmonary bypass (CPB) time was 229 min, cross-clamp time was 146 min, and total circulatory arrest time was 20 min. Postoperatively, pulses returned in the right lower extremity, with complete resolution of ischemia and no sequelae. No ischemia-reperfusion complications, such as severe metabolic acidosis, occurred. The patient stayed in the intensive care unit for eight days due to respiratory issues and was discharged after 15 days with no residual deficits. Follow-up CT showed contrast filling in both femoral arteries (Figure 2)

Figure 2. Postoperative computed tomography showing restored bilateral femoral perfusion.

In the present case, the patient exhibited dynamic malperfusion of the right lower extremity due to collapse of the true lumen at the iliac bifurcation. Arterial cannulation was achieved via the right femoral artery to access the true lumen. To preserve perfusion to the distal limb during Bentall procedure, a 10F catheter was introduced distal to the femoral cannulation site and connected to the CPB line. This allowed for simultaneous antegrade and retrograde flow during systemic circulation support, maintaining limb perfusion throughout the surgical period.

This approach is conceptually related to distal perfusion techniques commonly used in extracorporeal membrane oxygenation patients to prevent limb ischemia[3] but has been adapted here to the context of acute aortic dissection surgery. The advantage of this technique lies in its simplicity, timeliness, and compatibility with emergent operative settings without the need for additional surgical exposure or delayed reperfusion.

Postoperatively, the patient did not require any further intervention for the lower extremity. Ischemia resolved completely without evidence of neurologic or muscular sequelae. Although metabolic acidosis occurred transiently following reperfusion, it responded to standard medical management. These outcomes suggest that intraoperative maintenance of distal perfusion may contribute to mitigation of ischemia-reperfusion injury, an effect previously highlighted in the context of malperfusion management.[4,5]

The strategy employed aligns with evolving perspectives on individualized cannulation techniques in aortic dissection. Xia et al.[6] emphasized the utility of double arterial cannulation in providing both cerebral and distal organ perfusion, particularly in complex cases with compromised true lumen flow. While our approach does not involve formal double arterial cannulation in the classic sense, the use of a temporary distal perfusion line achieves a similar goal, ensuring effective systemic and peripheral circulation during the critical phases of aortic repair.

In conclusion, LEM in aortic dissection increases mortality and morbidity, and its optimal management remains unresolved. Our novel approach of temporary perfusion via a 10F catheter from the CPB line during dissection repair offers a simple, effective method to address LEM while enabling prompt dissection repair. This strategy may reduce ischemic complications in time-sensitive settings, warranting further investigation.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: All authors contributed equally to this article.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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2) Charlton-Ouw KM, Sandhu HK, Leake SS, Jeffress K, Miller CC Rd, Durham CA, et al. Need for limb revascularization in patients with acute aortic dissection is associated with mesenteric ıschemia. Ann Vasc Surg 2016;36:112-20. doi:10.1016/j.avsg.2016.03.012.

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6) Xia Q, Cao Y, Xie B, Qiu D, Deng L, Wang M, et al. Cannulation strategies in type A aortic dissection: A novel insight narrative review. J Thorac Dis 2021;13:2551-62. doi:10.21037/jtd-21-411.