Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissectionaEuro
Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissectionaEuro
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DOI：
10.1093/ejcts/ezv064
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发表时间：
2016-02-01
影响因子：
3.4
通讯作者：
Mohr, Friedrich-Wilhelm
中科院分区：
文献类型：
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作者：
Luehr, Maximilian;Etz, Christian D.;Mohr, Friedrich-Wilhelm
急性A型主动脉夹层（AADA）和继发于左颈总动脉（LCCA）或右颈总动脉（RCCA）闭塞或狭窄的脑灌注不良患者的管理是一项重大挑战。2005年11月至2013年7月期间，354例连续接受AADA手术的患者中有23例[中位年龄：66.3岁;四分位距（IQR）：55.2-69.9]因双侧（n = 1）或单侧LCCA/RCCA闭塞（n = 22）而出现脑灌注不良。AADA修复术包括半主动脉弓置换术（n = 14）或全主动脉弓置换术（n = 9）联合主动脉瓣修复术（n = 7）或置换术（n = 11）、根部置换术（n = 15）和冠状动脉搭桥术（n = 3）。所有患者均行解剖外颈动脉旁路术。在手术开始时进行主动脉-颈动脉旁路术，以允许单侧选择性脑灌注（n = 17; 73.9%）或在手术过程中，如果持续灌注不良的近红外光谱法（n = 6; 26.1%）怀疑。中位随访时间为15.2个月（IQR：4.8-34.1），100%完成。中位住院时间和ICU住院时间分别为16.0（IQR：12.5-26.0）和13.7（IQR：2.0-16.5）天。6例（26.1%）患者因出血或心脏压塞行再次开胸术。其他术后并发症包括体外膜肺氧合的低心输出量（n = 2; 8.7%），脓毒症（n = 4; 17.4%），呼吸功能不全（n = 10; 43.5%），肾衰竭伴临时透析（n = 7; 30.4%）和内脏灌注不良（n = 2; 8.7%），需要支架植入术（n = 1）或剖腹手术伴肠切除术（n = 1）。8例（34.8%）患者诊断为新发卒中伴或不伴永久性感觉或运动缺陷。9例（39.1%）患者出现暂时性神经功能缺损。住院和1年死亡率分别为13.0%和30.4%。23例患者36个月后的总生存期（组I =解剖外旁路）与其余331例无远端RCCA/LCCA闭塞的AADA患者（组II =无解剖外旁路），组I为69.6%（n = 16），组II为72.5%（n = 240）（P = 0.90）。LCCA或RCCA闭塞的解剖外旁路允许AADA修复期间的早期选择性脑灌注，并可能降低术前脑灌注不良患者的神经系统并发症风险。
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.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%).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).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.