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Combined Aortic Replacement And Stenting Of Cervicocerebral Arteries In Ascending Aortic And Arch Branches Dissection

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OBJECTIVE

Stanford type A aortic dissection is severe, life-threatening adverse event. The only method of treatment is surgery, which is associated with rather high (10-35%) hospital mortality rate [1]. Among several clinical features and complications of Stanford type A aortic dissection syncope and neurological symptoms may be focused on (table 1) [2]. Syncope occurs approximately in 15% of patients with type A aortic dissection, and may be related to supra-aortic vessel dissection. Neurological symptoms may also result from cerebral malperfusion due to dissection of cervicocerebral arteries. This dangerous condition affects up to one third of patients with type A aortic dissection, and there is no general way of management of these patients [3]. Dissection of cevicocerebral arteries may increase risk of perioperative adverse neurologic events during ascending aortic surgery [4].  There is still a lack of data concerning treatment of patients with concomitant carotid lesion and cardiac disease. 2 RCTs of patients with concomitant carotid and coronary arteries diseases were conducted, and there is very few and ambiguous data about patients with Stanford type A aortic dissection and concomitant carotid lesion [5,6,7,8]. The effect of hybrid approach, including ascending aortic replacement and preventive stenting of cervicocerebral arteries, remain to be fully understood.

 

AIM

To evaluate the short-term results of hybrid approach in patients with Stanford type A aortic dissection and arch branches dissection: combined ascending aortic replacement and stenting of cervicocerebral arteries.

 

METHODS

Between January 2010 and October 2016, a total of 42 consecutive patients (74% males) with Stanford type A aortic dissection (mean age 51.98 ± 11.31 years, 28 cases of acute dissection) involving carotid arteries were operated on. All patients were divided into two groups: isolated ascending aortic replacement (group 1, 33 patients) and hybrid (group 2, 9 patients) – combined ascending aortic replacement and preventive stenting of dissected cervicocerebral arteries due to the true lumen collapse > 70% independently of the neurological deficit (images 1 and 2).

 

RESULTS

The mean cardiopulmonary bypass time (178.20±8.53 in group 1 vs. 182.75±15.89 in group 2), cross-clamp time (127.43±7.01 vs. ­129.00±13.26) and circulatory arrest time (32,07±14,27 vs. 26,00±11,53) did not differ significantly. Hemiarch repair was performed in 35 patients (83.3%), and there were no cases of total arch replacement. In 71% we used axillary artery cannulation, in 24% - femoral, and in 5% - ascending aortic cannulation. We used antegrade unilateral cerebral perfusion and moderate (25-29OC) hypothermia in 77% and 50% of patients belonged to groups 1 and 2, respectively, and deep (18-22OC) hypothermia alone was used in 23% and 50% of patients, respectively. Overall 30-day mortality was 7,1% (3 patients, 1 from group 1). Freedom from stroke was 86,7% in group 1 and ­83,3% in group 2. We revealed a negative correlation of stroke with axillary artery cannulation (r = -0,463, p = 0,01), and positive – with femoral cannulation (r = 0,411, p = 0,01). We found non-significantly increased mortality (p = 0,05) and similar rate of stroke (p = 0,443) in group 2 in comparison with group 1.

 

Conclusions

The perioperative stroke rate was similar in patients with and without additional procedures performed on cervicocerebral arteries. Preventive stenting of cervicocerebral arteries in ascending aortic dissection is not associated with a significant increase of the mortality and stroke rate in patients with initially seriously affected major branches of the aortic arch. In case of femoral cannulation such patients are at increased risk of adverse neurologic events.

 

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