Aggressive direct perfusion of the carotid artery for acute type A aortic dissection complicated with brain malperfusion

P0034 

Abstract Submission 

Kyokun Uehara (1), Taku Shirakami (1), Junpei Kobiki (1), Takashi Tsuji (1), Manabu Morishima (1), Yoshio Arai (1)

(1) Tenri Hospital, Tenri, Nara

Kyokun Uehara    -  Contact Me
Tenri Hospital

Taku Shirakami    -  Contact Me
Tenri Hospital

Junpei Kobiki    -  Contact Me
Tenri Hospital

Takashi Tsuji    -  Contact Me
Tenri Hospital

Manabu Morishima    -  Contact Me
Tenri Hospital

Yoshio Arai    -  Contact Me
Tenri Hospital

Kyokun Uehara    -  Contact Me
National Cerebral and Cardiovascular Center

Objectives:
Brain malperfusion secondary to acute aortic dissection results in higher in-hospital mortality. Some patients develop permanent neurological deficit even after central aortic repair. We evaluated surgical results of direct perfusion to the carotid artery during acute type A aortic dissection (AAAD) repair complicated with brain malperfusion.

Methods: Among 175 patients who underwent aortic repair for AAAD from 2014 to 2022, brain malperfusion was recognized in 21(12%) patients. Brain malperfusion was defined as stenosis or occlusion of the unilateral or bilateral carotid artery on computed tomography. Age at surgery was 70 years (53-89) and nine (42.9%) patients were male. Preoperative consciousness level was alert in four (19.0%) patients, drowsy in four (19.0%), and coma in two (9.5%). Thirteen (61.9%) patients had preoperative hemiplegia, six (28.6%) had dysarthria, and five (23.8%) conjugate deviations. Four of eighteen patients undergoing preoperative computed tomography already showed developed cerebral infarction. Eight (38.1%) patients had direct perfusion of unilateral or bilateral carotid arteries before starting systemic cardiopulmonary bypass. Conventional antegrade cerebral perfusion under circulatory arrest was applied in thirteen (61.9%) patients. Of eight patients with direct cannulation, total arch replacement was performed in two (25.0%) patients, partial arch in four (50.0%), and hemiarch in two (25.0%).
Results: There was no in-hospital mortality. Seven (87.5%) of eight patients undergoing direct cannulation and 11 (84.6%) of patients with conventional cerebral perfusion showed improvement of neurological signs (p=0.43). Six (75.0%) of eight patients with direct cannulation discharged ambulatory (1 in conventional cerebral perfusion, p=0.0019). One of four patients with cerebral infarction detected on preoperative computed tomography completely recovered after decompressive craniectomy, however, remaining three patients resulted in coma even after AAAD repair (1 in direct cannulation and two in conventional cerebral perfusion).
Conclusion: Aggressive direct reperfusion of the carotid artery before the aortic repair may reduce neurological complications during AAAD repair in patients with brain malperfusion. However, further investigation would be required in patients with established infarction before AAAD repair.

Dissection