Management of mesenteric malperfusion or ischaemia in patients with acute type A aortic dissection (ATAAD) has been controversial and it remains unclear as to the best strategy for mesenteric revascularization. Available approaches for mesenteric artery revascularization include endovascular fenestration/stenting, open surgery (e.g. mesenteric artery bypass, direct perfusion) and hybrid approaches. Current guidelines on acute mesenteric ischaemia (AMI) are mainly based on evidence from aetiologies other than aortic dissection [1, 2], with scarce data from patients with ATAAD. In this sense, the study by Yamamoto et al. [3] sheds light on the efficacy of open surgical revascularization with direct mesenteric perfusion in the management of AMI in ATAAD, stimulating reflections about its roles in managing this extremely high-risk group of patients.

Although open surgical revascularization is recommended over endovascular options for AMI in current guidelines [1, 2], recent studies have shown endovascular technique was associated with lower rates of morbidity and 30-day mortality [1, 4] compared to open revascularization. While Yamamoto et al. achieved a comparable mortality of 20% to contemporary series [5], so far experience with direct mesenteric perfusion, including the present series of 10 patients [3], is limited to fewer than 20 patients [6]. Such scarce experience does not imply any definite benefit and is less likely to affect clinical practice.