Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.
Gen Thorac Cardiovasc Surg. 2021 Nov;69(11):1467-1475. doi: 10.1007/s11748-021-01628-y. Epub 2021 Apr 2.
Acute type A aortic dissection complicated with brain ischemia is associated with significantly higher mortality risks. Even if rescued with central aortic repair, some patients develop permanent postoperative neurological deficiency postoperatively. We recently introduced direct common carotid artery perfusion for acute type A aortic dissection involving the common carotid artery. This study introduced this technique to prevent postoperative neurological deficiency by comparing brain protection strategies.
Among 91 acute type A aortic dissection patients treated at our hospital during August 2015-October 2020, the common carotid artery was involved in 19 (21%), which had > 90% stenosis in either of the carotid arteries on preoperative contrast-enhanced computed tomography. Twelve patients underwent conventional selective cerebral perfusion during August 2015-December 2018 and seven patients underwent direct carotid artery perfusion during January 2019-October 2020. We assessed patient characteristics, surgical courses, clinical outcomes, and neurological outcomes.
The mean age was 69 (range 39-84) years; 17 patients were male (89%). Eight patients (42%) had neurological symptoms. Concomitant procedures, postoperative neurological symptoms, and late mortality were significantly associated with conventional selective cerebral perfusion. Five selective cerebral perfusion patients experienced worsened neurological symptoms and two died of broad cerebral ischemia. No direct carotid artery perfusion patient died during hospitalization or experienced worsened neurological outcomes.
Direct carotid artery perfusion may be useful in aortic dissection with brain ischemia because it does not aggravate neurological symptoms and is not associated with intraoperative cerebral infarction. However, it may be ineffective when cerebral infarction has already developed.
急性 A 型主动脉夹层合并脑缺血与更高的死亡率显著相关。即使通过主动脉修复得到救治，一些患者术后仍会发生永久性的术后神经功能缺损。我们最近引入了直接颈总动脉灌注治疗累及颈总动脉的急性 A 型主动脉夹层。本研究通过比较脑保护策略，介绍了这种预防术后神经功能缺损的技术。
在我们医院 2015 年 8 月至 2020 年 10 月期间治疗的 91 例急性 A 型主动脉夹层患者中，有 19 例（21%）颈总动脉受累，术前对比增强 CT 显示颈动脉中有一条或两条动脉狭窄>90%。2015 年 8 月至 2018 年 12 月期间，12 例患者接受常规选择性脑灌注，2019 年 1 月至 2020 年 10 月期间，7 例患者接受直接颈动脉灌注。我们评估了患者的特征、手术过程、临床结局和神经结局。
平均年龄为 69 岁（范围 39-84 岁）；17 例为男性（89%）。8 例（42%）患者有神经症状。伴发手术、术后神经症状和晚期死亡率与常规选择性脑灌注显著相关。5 例选择性脑灌注患者出现神经症状恶化，2 例死于广泛脑缺血。没有直接颈动脉灌注患者在住院期间死亡或出现神经功能恶化。
直接颈动脉灌注可能对合并脑缺血的主动脉夹层有用，因为它不会加重神经症状，与术中脑梗死无关。然而，当已经发生脑梗死时，它可能无效。
