Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissection.
OBJECTIVE
Management of patients with acute aortic dissection type A (AADA) and cerebral malperfusion secondary to occlusion or stenosis of the left common carotid artery (LCCA) or right common carotid artery (RCCA) is a significant challenge. The aim of this study is to present our institutional strategy and postoperative results for this high-risk patient cohort.


METHODS
Between November 2005 and July 2013, 23 of 354 consecutively operated AADA patients [median age: 66.3; interquartile range (IQR): 55.2-69.9] suffered from cerebral malperfusion due to bilateral (n = 1) or unilateral occlusion of the LCCA/RCCA (n = 22). AADA repair comprised hemi- (n = 14) or total (n = 9) arch replacement in combination with aortic valve repair (n = 7) or replacement (n = 11), root replacement (n = 15) and coronary bypass (n = 3). Extra-anatomic aorto-carotid bypass was performed in all patients. Aorto-carotid bypass was performed at the beginning of the procedure to allow for unilateral selective cerebral perfusion (n = 17; 73.9%) or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (n = 6; 26.1%).


RESULTS
The median follow-up was 15.2 months (IQR: 4.8-34.1) and 100% complete. Median hospital stay and ICU stay were 16.0 (IQR: 12.5-26.0) and 13.7 (IQR: 2.0-16.5) days, respectively. Rethoracotomy for haemorrhage or cardiac tamponade was performed in 6 (26.1%) patients. Other postoperative complications comprised low cardiac output with extracorporeal membrane oxygenation (n = 2; 8.7%), sepsis (n = 4; 17.4%), respiratory insufficiency (n = 10; 43.5%), renal failure with temporary dialysis (n = 7; 30.4%) and visceral malperfusion (n = 2; 8.7%) requiring stent grafting (n = 1) or laparotomy with intestinal resection (n = 1). New stroke with or without permanent sensory or motor deficit was diagnosed in 8 (34.8%) patients. Temporary neurological deficits were seen in 9 (39.1%) individuals. Hospital and 1-year mortality rates were 13.0 and 30.4%, respectively. Overall survival after 36 months of the 23 patients (Group I = Extra-anatomic bypass) versus the remaining 331 AADA patients without distal RCCA/LCCA occlusion (Group II = no extra-anatomic bypass) was 69.6% (n = 16) in Group I vs 72.5% (n = 240) in Group II (P = 0.90).


CONCLUSIONS
Extra-anatomic bypass for LCCA or RCCA occlusion allows for early selective cerebral perfusion during AADA repair, and may reduce the risk of neurological complications in patients with preoperative cerebral malperfusion.
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany mail@dr-luehr.net.
Maximilian
M
Luehr
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
Christian D
CD
Etz
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
Michal
M
Nozdrzykowski
Department of Radiology, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
Lukas
L
Lehmkuhl
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
Martin
M
Misfeld
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
Farhad
F
Bakhtiary
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany Division of Cardiac, Thoracic and Vascular Surgery, Columbia University Medical Centre, New York, NY, USA.
Michael A
MA
Borger
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
Friedrich-Wilhelm
FW
Mohr
D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000150:complications* / Q000601:surgery; D001014:Aortic Aneurysm / Q000150:complications* / Q000601:surgery; D002545:Brain Ischemia / Q000209:etiology / Q000601:surgery*; D002340:Carotid Artery Diseases / Q000150:complications / Q000601:surgery*; D017536:Carotid Artery, Common / Q000601:surgery*; D002548:Cerebral Revascularization / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome
Carotid cannulation; Cerebral malperfusion; Distal carotid artery occlusion; Neurological complications; Selective cerebral perfusion; Stroke; Type A aortic dissection