Perfusion and repair technique in acute aortic dissection with cerebral malperfusion and damage of the innominate artery

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients.

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Surgical Results of Acute Aortic Dissection Complicated With Cerebral Malperfusion

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2004.12.049 ◽

2005 ◽

Vol 80 (1) ◽

pp. 72-76 ◽

Cited By ~ 44

Author(s):

Hiroshi Tanaka ◽

Kenji Okada ◽

Teruo Yamashita ◽

Yoshihisa Morimoto ◽

Yujiro Kawanishi ◽

...

Keyword(s):

Aortic Dissection ◽

Acute Aortic Dissection ◽

Surgical Results ◽

Cerebral Malperfusion

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Urgent simultaneous revascularization of the carotid artery and ascending aortic replacement for type A acute aortic dissection with cerebral malperfusion

General Thoracic and Cardiovascular Surgery ◽

10.1007/s11748-007-0126-6 ◽

2007 ◽

Vol 55 (7) ◽

pp. 284-286 ◽

Cited By ~ 3

Author(s):

Keishi Ueyama ◽

Kennji Otaki ◽

Makoto Koyama ◽

Hiroyasu Kamiyama

Keyword(s):

Carotid Artery ◽

Aortic Dissection ◽

Acute Aortic Dissection ◽

Type A ◽

Aortic Replacement ◽

Ascending Aortic Replacement ◽

Cerebral Malperfusion

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Surgical treatment of type A acute aortic dissection with cerebral malperfusion: a systematic review

10.22541/au.163700485.51035911/v1 ◽

2021 ◽

Author(s):

Changtian Wang ◽

LEI ZHANG ◽

tao li ◽

Zhilong Xi ◽

Haiwei Wu ◽

...

Keyword(s):

Systematic Review ◽

Surgical Treatment ◽

Aortic Dissection ◽

Acute Aortic Dissection ◽

Surgical Repair ◽

Type A ◽

Mortality And Morbidity ◽

Medline Search ◽

Cerebral Malperfusion

Purpose: Type A acute aortic dissection (TAAAD) complicated with cerebral malperfusion (CM) is a life-threatening condition associated with high mortality, poor outcomes, and the optimal surgical management remains controversial. The aim of this review was to report the current results of surgical interventions of these patients. Methods: A systematic review was performed using PubMed and MEDLINE search for cases underwent surgical repair for TAAAD with CM. Demographics, neurological symptom, the time from onset of symptoms to operation, operation data, mortality, neurological outcome, and follow-up were reviewed. Results: A total of 363 patients with mean age of 65.7±13 years underwent surgical repair for TAAAD with CM were identified in 12 retrospective studies. In-hospital mortality was 20.1%. Mean duration of follow-up was 40.1 ± 37.6 months. The involved supra-aortic branch vessels were RCCA (n=99), LCCA (n=25) , B-CCA (n=52), CCA (n=131), IA (n=19), and LSA (n=8). Time from onset of neurological symptoms to surgery was 13.3 hours. Antegrade and/or retrograde cerebral perfusion was applied. Postoperatively, improved, unchanged and worsened neurological status was occurred in 54.3%, 27.1%, and 8.5%, respectively in 199 patients. Conclusion: The outcomes of surgical treatment of TAAAD complicated with CM indicate acceptable early mortality and morbidity. It is reasonable to perform lifesaving surgery on these patients. Early central surgical repair and reperfusion of brain may improve the outcomes.

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Aggressive strategy to save the brain in a case of acute aortic dissection

10.22541/au.162698041.19277518/v1 ◽

2021 ◽

Author(s):

Kenji Minatoya

Keyword(s):

Case Report ◽

Carotid Artery ◽

Aortic Dissection ◽

Cerebral Perfusion ◽

Carotid Arteries ◽

Acute Aortic Dissection ◽

Extraanatomical Bypass ◽

Cerebral Malperfusion ◽

Common Carotid Arteries ◽

The Brain

The case report by Sicim et al. is the placement of extra-anatomical bypasses in bilateral common carotid arteries. The similar previous reports of the extra-anatomical bypass usually indicate unilateral bypass. Whether or not the Willis’ circle is incomplete is difficult to judge during emergency surgery, and the authors’ judgment seems to have been correct in the sense that it could maintain cerebral perfusion reliably and quickly. The direct perfusion and extraanatomical bypass of carotid artery is a reasonable strategy in patients with cerebral malperfusion.

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Hybrid Stepwise External Wrapping for Type A Acute Aortic Dissection with Cerebral Malperfusion

10.21203/rs.3.rs-70045/v1 ◽

2020 ◽

Author(s):

Yoshihiro Suematsu ◽

Satoshi Nishi ◽

Daisuke Arima ◽

Akihiro Yoshimoto

Keyword(s):

Aortic Dissection ◽

Acute Aortic Dissection ◽

Aortic Rupture ◽

False Lumen ◽

Type A ◽

Good Physical Condition ◽

Threatening Condition ◽

Valve Insufficiency ◽

Life Threatening ◽

Cerebral Malperfusion

Abstract Background: Acute aortic dissection (AAD) is a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A AAD (TAAAD) still remains high, and treatment for such patients remains controversial. We report a successful treatment of TAAAD with a communicating false lumen in a 60-year-old man with acute hemi-cerebral malperfusion. Case presentation: The ascending aorta was wrapped with stepwise external wrapping (SEW) procedure, and subsequent thoracic endovascular aortic repair (TEVAR) was successfully performed. The patient was discharged in good physical condition without any complications. Conclusions: Hybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky.

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Abstract 19334: Management and Outcomes of Acute Retrograde Type A Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection

Circulation ◽

10.1161/circ.132.suppl_3.19334 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Foeke J Nauta ◽

Joon Bum Kim ◽

Himanshu J Patel ◽

Mark D Peterson ◽

Hans-Henning Eckstein ◽

...

Keyword(s):

Aortic Dissection ◽

Acute Aortic Dissection ◽

Innominate Artery ◽

Type A ◽

Ascending Aorta ◽

Early Mortality ◽

Long Term Results ◽

Descending Aorta ◽

International Registry

Background: Presentations and outcomes of acute aortic dissection (AD) with an entry tear in the ascending aorta may differ from retrograde dissection with an entry tear in the descending aorta. However, guidelines recommend urgent surgical repair for both entities. Methods and Results: All patients with AD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2014 were analyzed. We identified 99 patients (67 men; 63.2±14.0 years) with an entry tear in the descending aorta and retrograde extension into the arch or ascending aorta. Overall, independent predictors of retrograde type A AD were increasing age(OR 1.0; 95% CI, 1.0 to 1.0; P=0.004), history of cocaine abuse (OR 4.9; 95% CI, 1.7 to 13.6; P=0.003), back pain at presentation (OR 2.1; 95% CI, 1.3 to 3.3; P=0.002), and non-white race (OR 0.4; 95% CI, 0.2 to 0.6; P<0.001). During initial hospitalization, 44 of these patients were managed medically (MED), 33 with open surgery(SURG) and 22with endovascular therapy (ENDO). Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04). The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extension confined to zone 1 (proximal arch, P<0.001), whereas most of the SURG patients (71.8%) presented with AD extension into zone 0 (proximal to the innominate artery, P<0.001). Early (30-day or in-hospital) mortality rates of the MED, SURG and ENDO groups were 9.1%, 18.2%, and 13.6%, respectively (P=0.51), with 5-year survival of 86.7%, 80.0%, and 90.9%, respectively (mean follow-up, 3.3 years, log rank P=0.67). A trend of favorable early mortality was observed in patients with retrograde extension till zone 1 (8.6%) versus into zone 0 (18.6%, P=0.14).Early mortality of patients with retrograde type A AD (12.9%) was lower than those with type A AD (20.0%, P=0.001), while 5-year survival was similar (86.8% and 89.5%, respectively, mean follow-up, 3.0 years, log rank P=0.96). Conclusion: There is a subset of patients with acute retrograde type A AD who can be managed non-operatively with acceptable short and long-term results. This implies that a selective approach may be reasonable, particularly among those with proximal extension limited to the arch distal to the innominate artery.

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