Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissection.

OBJECTIVES: Management of patients with acute aortic dissection type A (AADA) and cerebral malperfusion secondary to occlusion or stenosis of the left common carotid artery (LCCA) or right common carotid artery (RCCA) is a significant challenge. The aim of this study is to present our institutional strategy and postoperative results for this high-risk patient cohort. METHODS: Between November 2005 and July 2013, 23 of 354 consecutively operated AADA patients [median age: 66.3; interquartile range (IQR): 55.2–69.9] suffered from cerebral malperfusion due to bilateral (n= 1) or unilateral occlusion of the LCCA/RCCA (n= 22). AADA repair comprised hemi- (n= 14) or total (n= 9) arch replacement in combination with aortic valve repair (n= 7) or replacement (n= 11), root replacement (n= 15) and coronary bypass (n= 3). Extra-anatomic aorto-carotid bypass was performed in all patients. Aortocarotid bypass was performed at the beginning of the procedure to allow for unilateral selective cerebral perfusion (n= 17; 73.9%) or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (n= 6; 26.1%). RESULTS: The median follow-up was 15.2 months (IQR: 4.8–34.1) and 100% complete. Median hospital stay and ICU stay were 16.0 (IQR: 12.5–26.0) and 13.7 (IQR: 2.0–16.5) days, respectively. Rethoracotomy for haemorrhage or cardiac tamponade was performed in 6 (26.1%) patients. Other postoperative complications comprised low cardiac output with extracorporeal membrane oxygenation (n= 2; 8.7%), sepsis (n= 4; 17.4%), respiratory insufficiency (n= 10; 43.5%), renal failure with temporary dialysis (n= 7; 30.4%) and visceral malperfusion (n= 2; 8.7%) requiring stent grafting (n= 1) or laparotomy with intestinal resection (n= 1). New stroke with or without permanent sensory or motor deficit was diagnosed in 8 (34.8%) patients. Temporary neurological deficits were seen in 9 (39.1%) individuals. Hospital and 1-year mortality rates were 13.0 and 30.4%, respectively. Overall survival after 36 months of the 23 patients (Group I=Extra-anatomic bypass) versus the remaining 331 AADA patients without distal RCCA/LCCA occlusion (Group II=no extra-anatomic bypass) was 69.6% (n=16) in Group I vs 72.5% (n=240) in Group II (P=0.90). CONCLUSION: Extra-anatomic bypass for LCCA or RCCA occlusion allows for early selective cerebral perfusion during AADA repair, and may reduce the risk of neurological complications in patients with preoperative cerebral malperfusion.