Staged bowel resection guided by intraoperative indocyanine green fluorescence angiography in the management of acute type a aortic dissection with mesenteric malperfusion: a case report.

BACKGROUND: Acute type A aortic dissection(aTAAD) complicated by mesenteric malperfusion (MMP) is associated with a high mortality rate due to bowel necrosis and subsequent multiorgan failure [(Yang B et al. in J Thorac Cardiovasc Surg 158:675-687 e674, 2019), (Wang C et al. in Rev Cardiovasc Med 24:127, 2023)]. The optimal management strategy remains controversial, particularly regarding the timing and extent of bowel resection. Extensive resection can lead to short bowel syndrome, resulting in chronic intestinal failure and poor nutritional outcomes. Here, we present a case of aTAAD successfully managed with staged bowel resection guided by intraoperative indocyanine green (ICG) fluorescence angiography. CASE PRESENTATION: A 29-year-old man presented with acute lower back pain and sensory deficits in both legs. He was diagnosed with acute type A aortic dissection and multiple malperfusions, including MMP. Emergency total aortic arch replacement with frozen elephant trunk was performed as central repair. Postoperatively, ischemic necrosis of the ascending colon was identified and resected, while the viability of the ileum remained uncertain. Intraoperative ICG fluorescence angiography confirmed adequate perfusion of the vasa recta, indicating reversible ischemia. To minimize unnecessary bowel resection, a second-look laparotomy surgery was performed 16 h later, leading to additional necrotic bowel resection. Ultimately, 180 cm of the ileum from the ligament of Treitz was preserved. The patient resumed oral intake approximately one month postoperatively and achieved full enteral independence by four months. CONCLUSIONS: This case highlights the importance of integrating ICG fluorescence angiography and staged bowel resection in the management of aTAAD with MMP. Early central repair, combined with real-time assessment of intestinal perfusion, enabled the preservation of intestinal length and improved postoperative outcomes. A strategic, stepwise approach is essential to optimizing bowel viability while maintaining hemodynamic stability in such critical situations.