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Author Spotlight: A Novel Approach to Cerebral Ischemia Modeling – Enhancing Reperfusion and Simplifying Procedure
Published on: May 31, 2024
Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in
Maximilian Luehr1, Christian D Etz2, Michal Nozdrzykowski2
1Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany mail@dr-luehr.net.
Insights
Extra-anatomic bypasses can improve outcomes for acute aortic dissection type A (AADA) patients with carotid artery occlusion. This strategy may reduce neurological complications in high-risk individuals.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Acute aortic dissection type A (AADA) with cerebral malperfusion due to carotid artery occlusion presents a significant management challenge.
- Cerebral malperfusion in AADA patients requires careful consideration for surgical intervention to prevent neurological deficits.
Purpose of the Study:
- To present an institutional strategy for managing AADA patients with LCCA or RCCA occlusion.
- To evaluate the postoperative outcomes and survival rates for this high-risk patient cohort.
Main Methods:
- A retrospective review of 354 AADA patients operated between November 2005 and July 2013.
- Analysis of 23 patients with cerebral malperfusion due to LCCA/RCCA occlusion, all of whom underwent extra-anatomic aorto-carotid bypass.
- Surgical repair involved hemi- or total arch replacement, aortic valve procedures, root replacement, and coronary bypass, with bypass performed either pre-emptively or during the procedure.
Main Results:
- Median follow-up was 15.2 months. Postoperative complications included re-thoracotomy (26.1%), low cardiac output (8.7%), sepsis (17.4%), respiratory insufficiency (43.5%), and renal failure (30.4%).
- New stroke occurred in 34.8% of patients, with temporary neurological deficits in 39.1%.
- Hospital and 1-year mortality rates were 13.0% and 30.4%, respectively. 36-month survival was comparable between patients with and without extra-anatomic bypass (69.6% vs 72.5%, P=0.90).
Conclusions:
- Extra-anatomic bypass facilitates early selective cerebral perfusion during AADA repair in cases of LCCA or RCCA occlusion.
- This approach may mitigate the risk of neurological complications in patients experiencing preoperative cerebral malperfusion.
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. Aorto-carotid 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.
