P097. Delayed Surgical Repair of Acute Type A Aortic Dissection with Concurrent Stroke
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
Thomas Jefferson University Hospital
philadelphia, PA
United States - Contact Me
Joshua Chen is a 3rd year medical student at Sidney Kimmel Medical College interested in a career in academic cardiothoracic surgery.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objective: Immediate versus delayed treatment of acute type A aortic dissection (ATAAD) with concurrent stroke in the absence of severe aortic insufficiency (AI) or aortic rupture is controversial. We report 2 cases of successful delayed repair of ATAAD with concurrent stroke.
Patient 1:
A 60-year-old hypertensive male presented in an unresponsive state with right gaze deviation.
Computerized tomography angiography (CTA) revealed an ATAAD extending from the sinotubular junction into the bilateral carotid arteries with decreased perfusion to the frontoparietal regions of the brain (Figure 1A). MRI demonstrated acute infarcts in the left hippocampus, cerebellum, and basal ganglia.
Because of the patient's significant neurological deficits, risk for hemorrhagic conversion and absence of severe AI or pericardial effusion on echocardiogram, a decision was made to delay surgical repair and treat the patient medically with strict blood pressure control and anticoagulants. Although the patient had residual left-sided hemiplegia, the patient was discharged approximately 2 months after admission with significant improvement in his neurological status. Two months later, the patient was taken for proximal aortic repair with bypasses to the bilateral carotid arteries using a trifurcated graft. Operative management included femoral artery cannulation, deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion.
Patient 2:
A 63-year-old hypertensive male with recurrent strokes and bicuspid aortopathy requiring aortic valve replacement 15 years ago presented with altered mental status, aphasia, and right-sided hemiplegia.
CTA revealed ATAAD originating from the aortic root with dissection flaps extending into the innominate and left carotid and subclavian arteries (Figure 1B). Echocardiogram showed no severe AI or pericardial effusion. Brain MRI revealed several ischemic infarcts in the left cerebral hemisphere. Immediate surgical repair was delayed due to the patient's significant neurological deficits. Strict blood pressure control was maintained, and the patient was monitored for symptom progression. Three days later, computed tomography of the head revealed new watershed infarcts in the left hemisphere.
Repeat CTA 4 days later demonstrated partial false lumen thrombosis of the proximal root dissection and a decision was made to further delay surgery. The patient was subsequently discharged to a rehab facility. Five months later, the patient had complete resolution of his stroke symptoms. Interval CTA showed aortic dilation from 5.0 to 6.5 cm. The patient underwent proximal aortic repair and left carotid artery bypass with reoperative sternotomy, right subclavian cannulation, DHCA, and bilateral antegrade cerebral perfusion.
Results:
Patients 1 and 2 were discharged on PODs #21 and #11, respectively. On discharge, Patient 1 had residual, but improved left-sided hemiplegia from his initial stroke. Patient 2 had no significant neurological deficits or other complications on discharge.
Conclusions: When the risks of surgery, such as permanent neurological damage or hemorrhagic conversion outweigh the benefits, delayed repair of ATAAD with concurrent stroke is a feasible and safe approach.
Authors
Siddharth Vemuri (1), joshua chen (1), Vishal Shah (1), Colin King (1), Megary McCoy (1), Jacqueline McGee (1), Konstadinos Plestis (1)
Institutions
(1) Thomas Jefferson University Hospital, Philadelphia, PA
Patient 1:
A 60-year-old hypertensive male presented in an unresponsive state with right gaze deviation.
Computerized tomography angiography (CTA) revealed an ATAAD extending from the sinotubular junction into the bilateral carotid arteries with decreased perfusion to the frontoparietal regions of the brain (Figure 1A). MRI demonstrated acute infarcts in the left hippocampus, cerebellum, and basal ganglia.
Because of the patient's significant neurological deficits, risk for hemorrhagic conversion and absence of severe AI or pericardial effusion on echocardiogram, a decision was made to delay surgical repair and treat the patient medically with strict blood pressure control and anticoagulants. Although the patient had residual left-sided hemiplegia, the patient was discharged approximately 2 months after admission with significant improvement in his neurological status. Two months later, the patient was taken for proximal aortic repair with bypasses to the bilateral carotid arteries using a trifurcated graft. Operative management included femoral artery cannulation, deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion.
Patient 2:
A 63-year-old hypertensive male with recurrent strokes and bicuspid aortopathy requiring aortic valve replacement 15 years ago presented with altered mental status, aphasia, and right-sided hemiplegia.
CTA revealed ATAAD originating from the aortic root with dissection flaps extending into the innominate and left carotid and subclavian arteries (Figure 1B). Echocardiogram showed no severe AI or pericardial effusion. Brain MRI revealed several ischemic infarcts in the left cerebral hemisphere. Immediate surgical repair was delayed due to the patient's significant neurological deficits. Strict blood pressure control was maintained, and the patient was monitored for symptom progression. Three days later, computed tomography of the head revealed new watershed infarcts in the left hemisphere.
Repeat CTA 4 days later demonstrated partial false lumen thrombosis of the proximal root dissection and a decision was made to further delay surgery. The patient was subsequently discharged to a rehab facility. Five months later, the patient had complete resolution of his stroke symptoms. Interval CTA showed aortic dilation from 5.0 to 6.5 cm. The patient underwent proximal aortic repair and left carotid artery bypass with reoperative sternotomy, right subclavian cannulation, DHCA, and bilateral antegrade cerebral perfusion.
Results:
Patients 1 and 2 were discharged on PODs #21 and #11, respectively. On discharge, Patient 1 had residual, but improved left-sided hemiplegia from his initial stroke. Patient 2 had no significant neurological deficits or other complications on discharge.
Conclusions: When the risks of surgery, such as permanent neurological damage or hemorrhagic conversion outweigh the benefits, delayed repair of ATAAD with concurrent stroke is a feasible and safe approach.
Authors
Siddharth Vemuri (1), joshua chen (1), Vishal Shah (1), Colin King (1), Megary McCoy (1), Jacqueline McGee (1), Konstadinos Plestis (1)
Institutions
(1) Thomas Jefferson University Hospital, Philadelphia, PA
Presentation Duration
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