Acute type A aortic dissection with cerebral malperfusion: diagnosis and repair using a novel technique

Though a rare condition, acute type A aortic dissection (ATAAD) is associated with high morbidity and mortality; hence, timely diagnosis and surgery are important to reduce the risk of mortality. If the dissection extends into the aortic arch branches, ensuring adequate cerebral perfusion during surgery is crucial to preventing stroke. A 50-year-old man presented to the emergency department with symptoms of acute chest pain, dizziness, and headache. His blood pressure was 180/110 mmHg and heart rate was 100 bpm. He had a high blood pressure and heart rate and was initially treated with glyceryl trinitrate. Initial investigations ruled out acute coronary syndrome. Further investigations revealed ATAAD with the involvement of arch branches, an incomplete (open) circle of Willis and cerebral malperfusion. He was prepared for a branch-first total aortic arch replacement. Due to the high risk of stroke in this patient, off-pump axillo-axillary bypass (adaptive perfusion technique) was used to ensure bihemispheric cerebral perfusion throughout the surgery. The surgery was uneventful, and the patient was discharged 12 days later. Postoperative follow-up at six months was normal. In conclusion, ATAAD is a surgical emergency that can mimic other acute thoracic conditions, such as pulmonary embolism and acute coronary syndrome; therefore, a judicious approach should be applied in the diagnosis and early management of symptoms. The reconstruction technique should be tailored to the patient's needs; as this patient had a poorly functioning circle of Willis and cerebral hypoperfusion, continuous bilateral cerebral perfusion was essential to prevent irreversible cerebral ischaemic insult. The adaptive technique is easy to learn for surgeons who are already proficient in aortic dissection procedures, it is reproducible and requires only minor changes to the surgical setup without any substantial increase in operative time. Adoption of this technique in other surgical centres could be beneficial in increasing the success rate for the treatment of ATAAD.