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. 2022 Feb 23:10:1-11.
doi: 10.1016/j.xjon.2022.01.024. eCollection 2022 Jun.

Early and late outcomes of type A acute aortic dissection with common carotid artery involvement

Taishi Inoue  1 , Atsushi Omura  1 , Shunya Chomei  1 , Hidekazu Nakai  1 , Katsuhiro Yamanaka  1 , Takeshi Inoue  1 , Kenji Okada  1
Affiliations

Early and late outcomes of type A acute aortic dissection with common carotid artery involvement

Taishi Inoue et al. JTCVS Open. .

Abstract

Objective: The relationship between common carotid artery (CCA) involvement in acute type A aortic dissection (ATAAD) and postoperative outcomes remains unclear. We investigated outcomes and described our current advanced strategy.

Methods: Of 492 patients who underwent surgical repair for ATAAD between September 1999 and February 2021, CCA involvement was identified in 114. Eighty of these 114 patients (70.2%) were classified as having a thrombosed CCA and 34 (29.8%) were classified as nonthrombosed. To prevent postoperative cerebral malperfusion, we initiated a strategy of early reperfusion and direct reconstruction of dissected and thrombosed CCAs regardless of neurologic symptoms.

Results: Fifty-five patients (48.2%) showed preoperative neurologic symptoms. No significant differences between the thrombosed and nonthrombosed groups were seen in postoperative mortality (20.0% vs 11.8%; P = .421) or frequency of postoperative modified Rankin scale (mRS) score ≥5 (30.0% vs 17.6%; P = .245). The rate of postoperative neurologic deficit was significantly higher (48.8% vs 23.5%; P = .013) and long-term survival rate was significantly lower (5 years; 59.1 ± 6.3% vs 77.9 ± 7.4%; 10 years: 50.0 ± 7.9% vs 72.3 ± 8.7%; P = .041) in the thrombosed group. Risk factors for mRS ≥5 from multivariable analysis included occluded thrombosed CCA, preoperative coma, preoperative shock, and prolonged operation time. Fifteen patients were treated with the early reperfusion and direct reconstruction strategy; postoperative mortality 13.3% (2 patients). No patients showed cerebral reperfusion syndrome.

Conclusions: In patients with CCA involvement, a thrombosed false lumen, especially an occluded CCA, resulted in worse outcomes regardless of preoperative neurologic symptoms. Further study is needed to evaluate the efficacy of the current strategy.

Keywords: ATAAD, acute type A aortic dissection; BSS, brain-saving system; CCA, common carotid artery; CT, computed tomography; ICA, internal carotid artery; IQR, interquartile range; PND, persistent neurologic deficit; TND, transient neurologic deficit; aortic dissection; carotid artery; cerebral perfusion; mRS, modified Rankin scale; malperfusion syndrome; stroke.

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Figures

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Graphical abstract
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A thrombosed false lumen results in worse outcomes.
Figure 1
Figure 1
Details and numbers of cases classified by severity of common carotid artery (CCA) stenosis. Cases involving a thrombosed CCA were divided into 3 subgroups by severity.
Figure 2
Figure 2
Scheme for the current strategy of early reperfusion and direct reconstruction. After the initiation of cardiopulmonary bypass, direct cannulation and direct reconstruction of the dissected common carotid artery were performed before central aortic repair.
Figure 3
Figure 3
Kaplan-Meier curves comparing survival in the thrombosed common carotid artery (CCA) and nonthrombosed CCA groups. The 95% confidence intervals are shown in parentheses. Long-term mortality was significantly higher in the thrombosed CCA group compared with the nonthrombosed group.
Figure 4
Figure 4
Outcomes for acute type A aortic dissection with common carotid artery (CCA) involvement. A thrombosed false lumen was associated high incidences of postoperative stroke and long-term death. Early reperfusion and direct reconstruction of the CCA might be useful. The 95% confidence intervals are also shown in the survival curve.
Figure E1
Figure E1
Preoperative head computed tomography (CT) and contrast-enhanced CT of the common carotid artery in patients with preoperative coma. Reentry was detected distal to the thrombosed false lumen. RCCA, Right common carotid artery.
See this image and copyright information in PMC

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