Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex; Memorial Hermann Heart and Vascular Institute - Texas Medical Center, Houston, Tex.
J Vasc Surg. 2013 Oct;58(4):910-6. doi: 10.1016/j.jvs.2013.03.042. Epub 2013 May 8.
Acute type A aortic dissection can extend into arch vessels, including the common carotid arteries. Although several reports describe concomitant endovascular repair of common carotid artery dissection (CCAD) during open ascending aortic repair, the criteria for repair, natural history, and risk of stroke are unclear. We examine the literature and our experience with nonoperative management of CCAD after acute aortic dissection repair to determine the risk of stroke and the need for carotid revascularization.
We queried our cases of type A aortic dissection over a 10-year period from January 2002 to December 2011. Imaging was reviewed to determine the presence of CCAD and degree of true-lumen stenosis. Analysis was performed to determine risk of stroke and survival on initial presentation and during follow-up. Survival functions between excluded groups and those with and without CCAD were compared using log-rank statistics.
We repaired 288 cases of acute type A aortic dissection during the study period. Adequate carotid imaging was available in 179 patients and comprised the study group. We identified 43 cases with CCAD (group A, 24.0%) and 136 cases without it (group B, 76.0%). History of previous stroke was not a risk factor for new stroke in either group (P = .517). Bilateral CCAD occurred in 16 cases (37.2%). Stroke on initial presentation was more common in group A (18.6%) than in group B (8.1%; odds ratio, 2.6; 95% confidence interval, 0.97-6.95; P = .051). Degree of stenosis or false-lumen thrombosis did not affect rate of stroke on presentation. The degree of postoperative true-lumen stenosis ranged from 0% (resolution) to 90%. No patient with CCAD had stroke or required carotid revascularization after discharge on follow-up. The 5-year, stroke-free survival rates in groups A and B were 69.7% and 73.6% (P = .820), respectively.
CCAD, due to extension from aortic arch dissection, has a low risk of subsequent stroke after the initial event. Based on current data, there is little evidence to suggest that aortic origin CCAD requires repair in the absence of recurrent symptoms, regardless of the degree of stenosis or false-lumen patency. Recommended optimal medical therapy includes either aspirin or anticoagulation for 6 months after initial presentation. Additional longitudinal studies are needed.
急性 A 型主动脉夹层可延伸至弓部血管，包括颈总动脉。虽然有几份报告描述了在开放升主动脉修复期间同时进行颈总动脉夹层（CCAD）的血管内修复，但修复标准、自然病程和中风风险尚不清楚。我们查阅了文献和我们在急性主动脉夹层修复后对 CCAD 的非手术治疗的经验，以确定中风风险和颈动脉血运重建的需要。
我们对 2002 年 1 月至 2011 年 12 月期间的 A 型主动脉夹层病例进行了查询。影像学检查以确定 CCAD 的存在和真腔狭窄程度。分析旨在确定初始表现和随访期间的中风风险和生存率。使用对数秩检验比较排除组与有和无 CCAD 组之间的生存函数。
研究期间，我们共修复了 288 例急性 A 型主动脉夹层。在 179 例患者中有足够的颈动脉成像，构成了研究组。我们共发现 43 例有 CCAD（A 组，24.0%）和 136 例无 CCAD（B 组，76.0%）。既往卒中史不是两组新发卒中的危险因素（P =.517）。双侧 CCAD 发生在 16 例（37.2%）中。A 组初始表现中卒中更为常见（18.6%），而 B 组（8.1%；优势比，2.6；95%置信区间，0.97-6.95；P =.051）。狭窄程度或假腔血栓形成并不影响初始表现的卒中发生率。术后真腔狭窄程度从 0%（完全缓解）到 90%。随访期间，无 CCAD 患者出院后无卒中或需要颈动脉血运重建。A 组和 B 组的 5 年无卒中生存率分别为 69.7%和 73.6%（P =.820）。
由于主动脉弓部夹层延伸所致的 CCAD，在初始事件后发生后续中风的风险较低。根据目前的数据，几乎没有证据表明主动脉起源的 CCAD 需要修复，除非有复发症状，无论狭窄程度或假腔通畅性如何。推荐的最佳药物治疗包括初始表现后 6 个月的阿司匹林或抗凝治疗。还需要进一步的纵向研究。
