Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Ann Thorac Surg. 2021 Aug;112(2):501-509. doi: 10.1016/j.athoracsur.2020.08.046. Epub 2020 Oct 27.
Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well investigated in the surgical literature.
Between 1997 and 2019, 775 patients presented with acute type A aortic dissection and 80 (10%) with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed.
Fifty-nine patients (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting, and 18 (23%) received nonoperative management. In-hospital mortality of all comers was 40.0%, and 81.3% were neurology related. Among the 45 patients (56%) in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion and 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. Six comatose patients (55%) were in the ICA group and 10 comatose patients (36%) in the CCA group (P = .28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. In contrast 79% of patients with unilateral or bilateral CCA occlusion survived to hospital discharge (P < .001), and only 3 (11%) had a neurologic death (P < .001).
ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurologic outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.
伴有脑灌注不良的 A 型主动脉夹层的治疗极具挑战性。尽管颅颈血管受累无疑是至关重要的，但在外科文献中并未得到充分研究。
1997 年至 2019 年间，775 例急性 A 型主动脉夹层患者中有 80 例（10%）伴有脑灌注不良。所有患者均从外院转来。回顾性查阅病历和影像学研究。
59 例（74%）患者行开放修复术，2 例（3%）患者行血管内主动脉修复术，2 例（3%）患者行颈动脉支架置入术，18 例（23%）患者行非手术治疗。所有患者的院内死亡率为 40.0%，81.3%与神经系统相关。45 例（56%）患者有颅颈血管影像学检查，其中 11 例（24%）颈内动脉（ICA）闭塞，28 例（62%）颈总动脉（CCA）闭塞而 ICA 无受累为责任病变。6 例昏迷患者（55%）位于 ICA 组，10 例昏迷患者（36%）位于 CCA 组（P=0.28）。所有 ICA 闭塞患者均发生脑水肿和脑疝综合征，无论治疗与否均死亡。相反，单侧或双侧 CCA 闭塞的患者 79%存活至出院（P<0.001），仅有 3 例（11%）发生神经死亡（P<0.001）。
无论手术方式如何，A 型主动脉夹层伴 ICA 闭塞可能是预后不良的神经学结局的替代标志物，而 CCA 闭塞或昏迷状态不应排除手术适应证。对于伴有脑灌注不良的患者，应及时行颈部 CT 血管造影检查。
