P034. Aggressive Direct Perfusion of the Carotid Artery for Acute Type A Aortic Dissection Complicated with Brain Malperfusion
National cerebral and cardiovascular center
Tenri, Osaka
Japan - Contact Me
Dr. Kyokun Uehara was appointed as Consultant Cardiac Surgeon and Senior Lecturer in 2016 at National Cerebral and Cardiovascular Center. His major interests in the field of clinical cardiac surgery include: open and endovascular surgery of the aorta, especially aortic root, arch and thoracoabdomimnal aorta, coronary artery bypass graft surgery, aortic valve surgery, adult congenital surgery, and surgery of the pulmonary artery.
Dr. Kyokun Uehara graduated in medicine from Nagoya City University, Japan. Subsequently, he completed his general surgical training at Kyoto University and affiliated hospitals. He embarked on a career in Cardiothoracic Surgery. He trained at Shizuoka Children’s Hospital and Tenri Hospital. He was awarded PhD at Kyoto University. He then subspecialized in heart and lung transplant surgery, adult cardiac surgery at St Vincent’s Hospital in Sydney, Australia.
Dr Kyokun Uehara operates on approximately 100 cases per annum. This is one of the largest cardiac surgical services in Japan. His overall mortality for all cases including complex and emergency aortic operations is 3%. One of his papers has been counted for the featured articles in the Journal of Thoracic and Cardiovascular Surgery.
Description
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.
Authors
Kyokun Uehara (1), Taku Shirakami (1), Junpei Kobiki (1), Takashi Tsuji (1), Manabu Morishima (1), Yoshio Arai (1)
Institutions
(1) Tenri Hospital, Tenri, Nara