Suspected Mesenteric Malperfusion in Acute Type A Aortic Dissection During Pregnancy: A Case Report and Review of Reperfusion-First Strategies.

Aortic dissection during pregnancy is rare but potentially catastrophic. Acute Type A aortic dissection generally requires urgent surgical repair. When visceral malperfusion is present, however, the optimal sequence of interventions may be complex, particularly when pregnancy and recent cesarean delivery increase operative risk. Endovascular reperfusion followed by delayed aortic repair has been proposed in selected patients, although evidence supporting this strategy in pregnancy remains limited. A 37-year-old woman at 31 weeks' gestation presented with chest and back pain. Initial CT pulmonary angiography (CTPA) performed for suspected pulmonary embolism excluded pulmonary embolism but demonstrated marked aortic root dilatation measuring 6.7 × 5.4 cm. Before definitive aortic imaging could be obtained, she developed acute respiratory deterioration and fetal distress, prompting emergency cesarean delivery under general anesthesia. Postoperatively, transthoracic echocardiography demonstrated severe aortic root and ascending aortic dilatation, severe aortic regurgitation, reduced left ventricular ejection fraction, and a dissection flap consistent with Type A aortic dissection. Because of concern for catastrophic hemorrhage associated with cardiopulmonary bypass and hypothermic circulatory arrest shortly after cesarean delivery, definitive aortic repair was deferred for approximately 24 h while the patient underwent medical optimization. During this interval, she developed progressive metabolic acidosis and worsening renal function, raising clinical concern for visceral malperfusion. Dedicated abdominal vascular imaging was not obtained, and therefore the presence, distribution, and mechanism of mesenteric malperfusion could not be anatomically confirmed before surgery. At subsequent operative exploration, extensive small- and large-bowel necrosis and markedly hypoperfused adnexal tissue were identified, precluding definitive aortic repair. The patient subsequently died after transition to comfort-focused care. In an analysis from the International Registry of Acute Aortic Dissection, mesenteric malperfusion was associated with higher in-hospital mortality than dissection without malperfusion. This case highlights the diagnostic and management challenges of acute Type A aortic dissection during pregnancy. In a pregnant patient presenting with chest or back pain and marked aortic root dilatation on PE-protocol imaging, acute aortic syndrome should prompt urgent evaluation of the entire aorta. Progressive metabolic acidosis, renal dysfunction, or unexplained clinical deterioration should raise concern for visceral ischemia. Although reperfusion-first strategies have been described in selected patients with aortic dissection and mesenteric malperfusion, their applicability in pregnancy remains uncertain and depends on defined vascular anatomy and the mechanism of malperfusion.