Novel brain computed tomography perfusion for cerebral malperfusion secondary to acute type A aortic dissection

Open in a separate window OBJECTIVESThe management of acute type A aortic dissection with malperfusion syndrome remains challenging. To evaluate preoperative condition, symptoms might be subjective and objective evaluation of cerebral artery has not yet been established. For quantitative evaluation, this study focused on brain computed tomography perfusion (CTP), which has been recommended by several guidelines of acute ischaemic stroke.METHODSIn the last 2 years, 147 patients hospitalized due to acute type A aortic dissection were retrospectively reviewed. Among the 23 (16%) patients with cerebral malperfusion, 14 who underwent brain CTP (6 preoperative and 8 postoperative) were enrolled. CTP parameters, including regional blood flow and time to maximum, were automatically computed using RApid processing of Perfusion and Diffusion software. The median duration from the onset to hospital arrival was 129 (31–659) min.RESULTSAmong the 6 patients who underwent preoperative CTP, 4 with salvageable ischaemic lesion (penumbra: 8–735 ml) without massive irreversible ischaemic lesion (ischaemic core: 0–31 ml) achieved acceptable neurological outcomes after emergency aortic replacement regardless of preoperative neurological severity. In contrast, 2 patients with an ischaemic core of >50 ml (73, 51 ml) fell into a vegetative state or neurological death due to intracranial haemorrhage. CTP parameters guided postoperative blood pressure augmentation without additional supra-aortic vessel intervention in the 8 patients who underwent postoperative CTP, among whom 6 achieved normal neurological function regardless of common carotid true lumen stenosis severity.CONCLUSIONSCTP was able to detect irreversible ischaemic core, guide critical decisions in preoperative patients and aid in determining the blood pressure augmentation for postoperative management focusing on residual brain ischaemia.     

Successful right common iliac to superior mesenteric artery bypass for mesenteric ischemia associated with acute aortic dissection: Report of a case

Mesenteric ischemia caused by obstruction of the superior mesenteric artery associated with acute aortic dissection was successfully treated by surgery in a 74-year-old man. The vein graft was effectively bypassed between the right common iliac artery and superior mesenteric artery on the day of onset of acute DeBakey type III b aortic dissection. He is currently well 1 year postoperatively on anti-hypertensive therapy.     

Improved survival of surgery for acute type a aortic dissection

Objectives: In the past decade, progress in cardiovascular technology has been incorporated into the surgical treatment of acute type A dissection resulting in remarkable improvement. Factors in this progress encompass rapid noninvasive diagnosis, intraoperative introduction of aprotinine, surgical glue, sealed grafts, and refined surgical technique. The objective of this study is to identify which factors contributed to the improvement of the surgical outcome of acute type A dissections. Methods: Between January 1989 and February 2001, 78 consecutive patients had emergency surgeries for acute type A dissection. The initial 31 patients (group I) received preoperative angiography, when possible. Since 1996, the next 47 patients (group II) have received noninvasive rapid diagnosis with hemostatic surgical management. This included aggressive proximal resection and judicious use of gelatin resorcine formol glue and felt strips. Between the two groups, in-hospital mortality and morbidity, incidence of neurological complications, late survival and cardiovascular events were compared. Risk factors for in-hospital death were investigated with univariate and multivariate analysis. Results: The in-hospital mortality was significantly improved in group II (4.3%) compared with group I (29.0%). Overall mortality was 14.1%. Multivariate analysis revealed preoperative limb ischemia and delayed timing of operation (>3 hours after arrival) as independent risk factors for in-hospital death. Late survival at 5 years was 61.5±7.5%. Between the two groups there was no significant difference in late survival or cardiovascular events. Conclusions: Immediate surgical intervention, using rapid noninvasive diagnosis with hemostatic management, substantially improves the surgical outcome of acute aortic dissection.     

Salvage extracorporeal membrane oxygenation for acute type A aortic dissection with coronary malperfusion

Perioperative use of extracorporeal membrane oxygenation (ECMO) in type A aortic dissection is a topic of contention with limited available data. We report the case of a patient presenting in severe cardiogenic shock due to coronary malperfusion and severe aortic insufficiency who was resucitated with ECMO as a bridge to recovery.     

Acute type A aortic dissection: the prognostic impact of preoperative cardiac tamponade

Objective: Acute type A aortic dissection requires emergency surgery and is associated with considerable mortality. The aim of the study was to evaluate whether occurrence of preoperative cardiac tamponade with or without palpable pulses in these patients is associated with higher incidence of multiple organ failure (MOF) and in-hospital mortality. Methods: A retrospective cohort study included 87 patients with acute type A aortic dissection, who were admitted via an emergency department between December 1991 and December 1999 for emergency surgery. Impending cardiac tamponade (with palpable pulses) and severe cardiac tamponade (without palpable pulses) were recorded and patients were followed for occurrence of MOF and/or in-hospital mortality. Results: Impending cardiac tamponade with palpable pulses was diagnosed in 33 patients (38%), signs of severe cardiac tamponade without palpable pulses were found in seven patients (8%). MOF occurred in 41 patients (47%); 32 patients (37%) died during the present stay, all of them had MOF. Preoperative severe cardiac tamponade without palpable pulses was associated with a significantly increased risk for poor outcome (odds ratio (OR)=16.1, 70% confidence interval (CI) 4.8–71.7, P=0.04), particularly preoperative death (n=6 of 7). Impending cardiac tamponade with palpable pulses (OR=1.6, 70% CI 0.8–3.3, P=0.2) was not associated with the occurrence of MOF/death. Hemodynamic shock (OR=6.5, 70% CI 3.0–13.9, P=0.01) was also associated with poor outcome. Conclusion: Patients with acute type A aortic dissection and signs of preoperative cardiac tamponade without palpable pulses had a 16-fold increased risk for poor outcome, particularly preoperative death. In contrast, cardiac tamponade with palpable pulses was not associated with increased frequency of MOF/in-hospital mortality.     

Malperfusion in acute type A aortic dissection: An update from the Nordic Consortium for Acute Type A Aortic Dissection

Objectives

To evaluate the effect of preoperative malperfusion on 30-day and late mortality and postoperative complications using data from the Nordic Consortium for Acute Type A Aortic Dissection (ATAAD) registry.

Changing predictors of postoperative mortality in acute type A aortic dissection

OBJECTIVES: Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies. METHODS: We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999. RESULTS: Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p < 0.01) and malperfusion of more than 1 vital organ (adjusted odds ratio 4.97, p < 0.01), especially myocardial ischemia due to coronary artery dissection (adjusted odds ratio 3.21, p < 0.05), significantly increased the likelihood of operative death. Multivariate logistic regression analysis showed only cardiopulmonary arrest (p < 0.01) and concomitant coronary artery bypass grafting necessitated in cases complicated by evolving myocardial infarction (p < 0.05) to be independent predictors of postoperative mortality. CONCLUSION: Preoperative complication from coronary dissection was the most important predictor of early postoperative mortality in this series. In such cases, rapid surgical intervention before myocardial infarction develops is vital to saving lives.     

Surgery for acute type a aortic dissection using retrograde cerebral perfusion

OBJECTIVE: We reviewed the surgical management of acute type A aortic dissection between 1989 and 1998. METHODS: Subjects were 28 consecutive patients (mean age: 61.8 +/- 10.7 years) with acute type A aortic dissection were studied. The mean duration between aortic dissection onset and surgery was 17.5 +/- 17.0 hours. In surgery, aortic pathology and flow patterns in dissected aortic channels were evaluated using transesophageal and epiaortic echo. Simple, safe combination of profound hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis was used for brain protection. Hypothermic circulatory arrest was 46.9 +/- 24.8 minutes. Aortic repair consisted in ascending aortic replacement in 5 patients, with hemiarch repair in 17, and total arch repair in 6. Intimal tears were resected in all but 2 patients. Concomitantly resuspension of the aortic valve was done in 9 and aortic root replacement in 2. RESULTS: No operative (30-day) deaths occurred, although 2 died from unrelated hepatic failure during hospitalization or late-stage pancreatic cancer in the late stage. In cerebral sequellae, 1 patient suffered a stroke and 2 patients developed temporary neurologic dysfunction. CONCLUSION: Our experience demonstrated that the simplified conjunction of hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis, associated with real-time assessment by transesophageal and epiaortic echo, is safe and useful during emergency aortic repair for acute type A aortic dissection.     

Urgent simultaneous revascularization of the carotid artery and ascending aortic replacement for type A acute aortic dissection with cerebral malperfusion

We report a case of successful urgent surgical therapy for a Stanford type A acute aortic dissection with cerebral malperfusion. A woman with a sudden severe chest pain consulted the emergency department. Computed tomography results showed a Stanford type A acute aortic dissection. She had repeating left paralysis, so a cerebrovascular study was performed. It showed that the collateral left carotid and vertebral arteries perfused only the right cerebral hemisphere. Hence, it was thought that the left paralysis was caused by cerebral malperfusion due to the dissection. Simple aortic replacement endangered the right cerebral hemisphere, so we performed urgent revascularization of the right carotid artery, followed by an ascending aortic replacement procedure.     

Emergency pericardial drainage without aortic repair for type A intramural haematoma complicated by cardiac tamponade

From April 2011 to March 2020, 87 patients with type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta were treated at Kitasato University Hospital. The initial watch-and-wait strategy without emergency aortic repair was taken in 52 cases in which the maximum aortic diameter was ≤50 mm, pain score on arrival at our hospital was ≤3/10 on the numerical rating scale and there was no ulcer-like projection (ULP) in the ascending aorta. Eleven patients who fulfilled the criteria but developed cardiac tamponade underwent emergency pericardial drainage without aortic repair. Among these 11 patients, 3 patients developed an aortic event during the hospitalization; 1 patient developed enlargement of the ULP 18 days later but refused surgery, another patient developed rupture of the dissected brachiocephalic artery 4 days later and underwent emergency repair of the ascending aorta and the brachiocephalic artery and the other patient developed a new ULP in the ascending aorta 14 days later and underwent aortic repair. All 11 patients were discharged home. During follow-up (3.0 ± 2.4 years), 1 patient developed a recurrent type A acute aortic dissection and underwent emergency aortic repair 29 months later. There was no aorta-related death.     

Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection

Background

The purpose of this study was to evaluate clinical, anatomic, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

Current trends in the management of acute type A aortic intramural hematoma

Within the spectrum of acute aortic syndromes, intramural hematoma (IMH) is a distinct lesion that is characterized by crescentic or circumferential thickening of the aortic wall in the absence of an intimal defect. The reported incidence of IMH among all type A acute aortic syndromes ranges from 3.5% to 28.3%. As compared with acute aortic dissection, IMH is a disease of the elderly, and it tends to have reduced rates of malperfusion syndromes, aortic insufficiency, and root dilation, yet also tends to have increased rates of pericardial effusion, cardiac tamponade, and periaortic hematoma. With respect to natural history, IMH may progress to classic dissection, frank rupture, or aneurysmal dilation; yet, IMH may also regress and be completely resorbed. However, studies disagree over the rates of progression or regression; as such, few studies agree on the short-term and long-term prognosis associated with IMH. American and European guidelines advocate emergent surgery for all acutely presenting type A IMH. At a minimum, supracoronary replacement of the aorta with hemiarch reconstruction is the preferred extent of operative repair to reduce rates of long-term reintervention for disease progression. However, valve and/or root procedures may be necessary proximally, while total arch reconstruction or hybrid procedures for the descending aorta may be necessary distally. Much remains unknown for IMH, including the ideal extent of aortic repair, risk-stratification for elderly patients, and the optimal treatment paradigm for stable, uncomplicated IMH. As such, IMH remains a diagnostic and therapeutic challenge for the cardiovascular surgeon.     

Preoperative fenestration for type A acute aortic dissection with mesenteric malperfusion

We report a case of a 71-year-old man presenting with acute type A aortic dissection and mesenteric ischemia due to extension of the intimal flap to the mesenteric artery. Because of the severity of the abdominal symptoms, surgical correction of the ascending aorta was delayed. Preoperative percutaneous fenestration was performed successfully, allowing ascending aortic replacement 6 days later. Transverse colon stenosis secondary to preoperative ischemia occurred in the postoperative course. The patient was discharged from hospital with normal intestinal transit 72 days later.     

Inducing false lumen thrombosis for retrograde type A aortic dissection

Background

How to choose the proximal landing zone in endovascular interventions for a patient with a patent retrograde false lumen in dissection of the ascending aorta and aortic arch remains unclear. This study sought to report the safety and efficiency of inducing thrombosis of the retrograde false lumen to enhance a proximal landing zone to treat retrograde type A aortic dissection.