title: Management of cerebral malperfusion in surgical repair of acute type A aortic dissection.
abstract: OBJECTIVE
  Cerebral malperfusion for patients with acute type A aortic dissection (AAAD) remains an unsolved problem. The present study aimed to evaluate our management of cerebral perfusion and identify predictors of perioperative cerebral malperfusion in patients undergoing surgical repair of AAAD.
  
  
  METHODS
  Between January 2004 and December 2015, 137 consecutive patients with AAAD underwent aortic replacement at Tsuchiya General Hospital. The status of the dissected supra-aortic branch vessels (SABVs) was classified as patent or thrombosis by preoperative computed tomographic angiography. Intraoperative cerebral perfusion was monitored by transcutaneous carotid echo and regional oxygen saturation. In cases with neurological symptoms or cerebral malperfusion, quick cerebral perfusion was immediately started using a quick cutdown technique. We assessed clinical outcomes, including mortality and complications, and analysed predictors of early mortality and cerebral malperfusion.
  
  
  RESULTS
  The early mortality rate was 8.0%. Postoperative cerebral injury was observed in 4 patients (2.9%). Nineteen patients had perioperative cerebral malperfusion. There were no postoperative cerebral injuries in the patients in whom intraoperative cerebral malperfusion was corrected. Multivariable analysis revealed that preoperative shock (odds ratio [OR] 22.60, P  < 0.0001) and extension of dissection to the abdominal aorta (OR 9.31, P  = 0.0064) were significant risk factors for early mortality. Preoperative neurological symptoms (OR 12.40, P  = 0.0006) and partial or complete thrombosis of the SABV (OR 64.10, P  < 0.0001) were identified as independent predictors of perioperative cerebral malperfusion.
  
  
  CONCLUSIONS
  Perioperative cerebral perfusion should be carefully managed, especially in the patients with preoperative neurological symptoms or partial or complete thrombosis of the SABV.
authors.affiliation: Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Naka-ku, Hiroshima, Japan.
authors.forename: Tomokuni
authors.initials: T
authors.lastname: Furukawa
authors.affiliation: Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Naka-ku, Hiroshima, Japan.
authors.forename: Naomichi
authors.initials: N
authors.lastname: Uchida
authors.affiliation: Department of Cardiovascular Surgery, Hiroshima University Hospital, Minami-ku, Hiroshima, Japan.
authors.forename: Shinya
authors.initials: S
authors.lastname: Takahashi
authors.affiliation: Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Naka-ku, Hiroshima, Japan.
authors.forename: Yoshitaka
authors.initials: Y
authors.lastname: Yamane
authors.affiliation: Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Naka-ku, Hiroshima, Japan.
authors.forename: Shingo
authors.initials: S
authors.lastname: Mochizuki
authors.affiliation: Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Naka-ku, Hiroshima, Japan.
authors.forename: Kazunori
authors.initials: K
authors.lastname: Yamada
authors.affiliation: Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Naka-ku, Hiroshima, Japan.
authors.forename: Takaaki
authors.initials: T
authors.lastname: Mochizuki
authors.affiliation: Department of Cardiovascular Surgery, Hiroshima University Hospital, Minami-ku, Hiroshima, Japan.
authors.forename: Taijiro
authors.initials: T
authors.lastname: Sueda
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000601:surgery*; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000601:surgery*; D002560:Cerebrovascular Circulation / Q000502:physiology; D005260:Female; D006801:Humans; D020767:Intracranial Thrombosis / Q000000981:diagnostic imaging / Q000517:prevention & control / Q000628:therapy; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000517:prevention & control / Q000628:therapy; D015424:Reperfusion; D012307:Risk Factors; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
keywords: Acute aortic dissection; Cerebral malperfusion; Thoracic aortic disease