Management Strategy in Patients with Type A Aortic Dissection Complicated by Cerebral Malperfusion

Yulia V. Grigoreva, Vladimir A. Mironenko, Nidal A. Darvish , Sergey V. Garmanov, Alexandr S. Shundrov, Lubov V. Chegrina

Bakulev Center, Moscow, Russia

Date, time and location: 2018.05.27 08:30, Congress Hall, 2F–B

Abstract

A significant dilemma is the treatment of patients with aortic dissection and preoperative cerebral malperfusion. The reported incidence of neurological deficit before surgery in type A aortic dissection (TAAD) patients varies between 6% and 20%. There is an ongoing debate about the best surgical strategy for TAAD in general and even more for the high-risk subgroup of patients with cerebral malperfusion.

Methods: between 2012-2017 in our institution 25 patients underwent surgical treatment of TAAD complicated by cerebral malperfusion. Most of the patients were males (52%) the mean age was (52,4±10,9) The central repair comprised hemi- (n =13 (52%) or total (n =12 (48%) arch replacement in combination with aortic valve replacement n =6 (26%). Innominate artery replacement was performed in a 20 patients, RCCA)/LCCA and RSA/LSA repair was required in 14 and 7 cases respectively . Staged approach was used in 6 cases to minimize surgical risks.

Several arterial cannulation strategies were applied. The choice of cannulation site was dictated by patient specifics.

Adaptive antegrade cerebral perfusion was routinely used. Several modalities for intraoperative assessment of perfusion was used, including transcranial dopplerography and near-infrared spectroscopy (NIRS).

Results:A period of moderate hypothermic circulatory arrest (CA) (mean 34,5±11,3 min) was used to direct inspection of the aortic arch and secure distal aortic and supra-aortic vessels reconstruction. In 6 cases (26%) visceral perfusion was performed which allowed to reduce CA to 13,7±5,6 min. There were 2 strokes (8%) in early postoperative period. Temporary neurological deficits were seen in 3(12%) individuals. Hospital mortality was 2 (8%).

Conclusions: aortic dissection with cerebral malperfusion requires individual planning of surgical tactics including the possibility of using staged treatment, different perfusion options, which reduces overall anoxia time and complication rate in this high-risk cohort of patients.