Aorto-carotid bypass at the time of central repair for type A acute aortic dissection to prevent ischemic stroke

P0056 

Case Video Submission 

Tomonobu Abe (1), Wataru Tatsuishi (2), Yasunobu Konishi (2), Atsushi Oi (2), Yuya Nozawa (2)

(1) Gunma University, Japan, (2) Gunma University, Maebashi, NA

Tomonobu Abe    -  Contact Me
Gunma University

Wataru Tatsuishi    -  Contact Me
Gunma University

Yasunobu Konishi    -  Contact Me
Gunma University

Atsushi Oi    -  Contact Me
Gunma University

Yuya Nozawa    -  Contact Me
Gunma University

Tomonobu Abe    -  Contact Me
N/A

Objective
Perioperative stroke is one of the most important complications of acute type A dissection surgery. We have been performing extra-anatomical aorto-carotid bypass in selected patients with static obstruction of the carotid artery with clinical signs of neurological deficit or marked intraoperative cerebral hypoxia without signs of cerebral edema. Mainly two situations, preoperative transient ischemic attack and intra-operative drop of regional oxygen saturation of the brain fit the principle.

Case Video Summary
The presented case was a 67 year old female. She was brought to our hospital 2 hours after the onset of backpain and weakness in the left lower limb. She opened her eyes and was able to tell her name. Computed tomography images showed 90% of static obstruction of the right catotid artery. The left external iliac artery was blocked.
Since this patient was neurologically intact, we planned usual central repair with exposure of the right neck in case. Pre-sternotomy carotid artery echo showed forward blood flow in the narrow true lumen. We did usual arch replacement with selective cerebral perfusion via the callulae for three vessels, which is the routine ajunctive methods in our institution. After completing the anastomosis to the brachiocepharic artery, there was a marked drop of regional oxygen saturation (RSO2) on the right forehead. The right carotid artery was exposed and echo showed that true lumen was completely blocked. We cut the adventitia and evacuated thrombus from the false lumen. There was some forward blood flow detected by echo. However, the saturation did not improve. We then cut the true lumen and confirmed the forward flow. We replaced a short part of the carotid artery. The saturation did not improve. We finally decided to do extra-anatomical bypass. After the completion the brain saturation markedly improved in the right side as well as some improvement in the left side.
We have been doing this procedure for five cases until the end of 2021 and having good results.

Conclusion
We consider Aorto-carotid bypass at the time of Central repair of Acute type A dissection may be useful to prevent perioperative stroke in some cases.

Dissection