Aggressive Aortic Arch and Carotid Replacement Strategy for Type A Aortic Dissection Improves Neurologic Outcomes
International registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome....
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| Vydané v: | The Annals of thoracic surgery Ročník 101; číslo 3; s. 896 |
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| Hlavní autori: | , , , , , , , |
| Médium: | Journal Article |
| Jazyk: | English |
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Netherlands
01.03.2016
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| Abstract | International registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome. We hypothesize that concomitant carotid dissection or complex dissection flaps in the arch play a major role in stroke development and that aggressive reconstruction of the arch and carotid arteries can improve neurologic outcomes in TAAD.
A standardized protocol focused on expedient care, neurocerebral protection, and common carotid and total arch reconstruction was developed for 264 consecutive TAADs. Arch and complete carotid replacement was based on arch dissection anatomy, carotid involvement, or an intraarch tear. Neurocerebral monitoring with continuous electroencephalogram/somatosensory evoked potentials was used in all cases.
The postoperative stroke and hospital mortality rates were 3.4% and 9.1%, and stroke rates by extent of arch replacement were 4%, 3%, and 0% for hemiarch, total arch, and total arch with complete carotid replacement, respectively. An intraoperative change in the electroencephalogram/somatosensory evoked potentials was strongly predictive of stroke and had a negative predictive value of 98.2%.
An algorithmic approach to TAAD including (1) rapid transport-to-incision-to-cardiopulmonary bypass established centrally, (2) neurocerebral monitoring, (3) liberal use of total arch replacement for clearly defined indications (and hemiarch for all others), and (4) common carotid arterial replacement for concomitant carotid dissections significantly improves outcomes. |
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| AbstractList | International registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome. We hypothesize that concomitant carotid dissection or complex dissection flaps in the arch play a major role in stroke development and that aggressive reconstruction of the arch and carotid arteries can improve neurologic outcomes in TAAD.
A standardized protocol focused on expedient care, neurocerebral protection, and common carotid and total arch reconstruction was developed for 264 consecutive TAADs. Arch and complete carotid replacement was based on arch dissection anatomy, carotid involvement, or an intraarch tear. Neurocerebral monitoring with continuous electroencephalogram/somatosensory evoked potentials was used in all cases.
The postoperative stroke and hospital mortality rates were 3.4% and 9.1%, and stroke rates by extent of arch replacement were 4%, 3%, and 0% for hemiarch, total arch, and total arch with complete carotid replacement, respectively. An intraoperative change in the electroencephalogram/somatosensory evoked potentials was strongly predictive of stroke and had a negative predictive value of 98.2%.
An algorithmic approach to TAAD including (1) rapid transport-to-incision-to-cardiopulmonary bypass established centrally, (2) neurocerebral monitoring, (3) liberal use of total arch replacement for clearly defined indications (and hemiarch for all others), and (4) common carotid arterial replacement for concomitant carotid dissections significantly improves outcomes. International registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome. We hypothesize that concomitant carotid dissection or complex dissection flaps in the arch play a major role in stroke development and that aggressive reconstruction of the arch and carotid arteries can improve neurologic outcomes in TAAD.BACKGROUNDInternational registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome. We hypothesize that concomitant carotid dissection or complex dissection flaps in the arch play a major role in stroke development and that aggressive reconstruction of the arch and carotid arteries can improve neurologic outcomes in TAAD.A standardized protocol focused on expedient care, neurocerebral protection, and common carotid and total arch reconstruction was developed for 264 consecutive TAADs. Arch and complete carotid replacement was based on arch dissection anatomy, carotid involvement, or an intraarch tear. Neurocerebral monitoring with continuous electroencephalogram/somatosensory evoked potentials was used in all cases.METHODSA standardized protocol focused on expedient care, neurocerebral protection, and common carotid and total arch reconstruction was developed for 264 consecutive TAADs. Arch and complete carotid replacement was based on arch dissection anatomy, carotid involvement, or an intraarch tear. Neurocerebral monitoring with continuous electroencephalogram/somatosensory evoked potentials was used in all cases.The postoperative stroke and hospital mortality rates were 3.4% and 9.1%, and stroke rates by extent of arch replacement were 4%, 3%, and 0% for hemiarch, total arch, and total arch with complete carotid replacement, respectively. An intraoperative change in the electroencephalogram/somatosensory evoked potentials was strongly predictive of stroke and had a negative predictive value of 98.2%.RESULTSThe postoperative stroke and hospital mortality rates were 3.4% and 9.1%, and stroke rates by extent of arch replacement were 4%, 3%, and 0% for hemiarch, total arch, and total arch with complete carotid replacement, respectively. An intraoperative change in the electroencephalogram/somatosensory evoked potentials was strongly predictive of stroke and had a negative predictive value of 98.2%.An algorithmic approach to TAAD including (1) rapid transport-to-incision-to-cardiopulmonary bypass established centrally, (2) neurocerebral monitoring, (3) liberal use of total arch replacement for clearly defined indications (and hemiarch for all others), and (4) common carotid arterial replacement for concomitant carotid dissections significantly improves outcomes.CONCLUSIONSAn algorithmic approach to TAAD including (1) rapid transport-to-incision-to-cardiopulmonary bypass established centrally, (2) neurocerebral monitoring, (3) liberal use of total arch replacement for clearly defined indications (and hemiarch for all others), and (4) common carotid arterial replacement for concomitant carotid dissections significantly improves outcomes. |
| Author | Lacomis, Joan M Balzer, Jeffrey R Navid, Forozan Gleason, Thomas G Jovin, Tudor G Althouse, Andrew D Trivedi, Dhaval Joshi, Rama |
| Author_xml | – sequence: 1 givenname: Dhaval surname: Trivedi fullname: Trivedi, Dhaval organization: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania – sequence: 2 givenname: Forozan surname: Navid fullname: Navid, Forozan organization: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania – sequence: 3 givenname: Jeffrey R surname: Balzer fullname: Balzer, Jeffrey R organization: Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania – sequence: 4 givenname: Rama surname: Joshi fullname: Joshi, Rama organization: Department of Anesthesiology, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania – sequence: 5 givenname: Joan M surname: Lacomis fullname: Lacomis, Joan M organization: Department of Radiology, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania – sequence: 6 givenname: Tudor G surname: Jovin fullname: Jovin, Tudor G organization: Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania – sequence: 7 givenname: Andrew D surname: Althouse fullname: Althouse, Andrew D organization: UPMC Heart & Vascular Institute, Pittsburgh, Pennsylvania – sequence: 8 givenname: Thomas G surname: Gleason fullname: Gleason, Thomas G email: gleasontg@upmc.edu organization: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania. Electronic address: gleasontg@upmc.edu |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/26542439$$D View this record in MEDLINE/PubMed |
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| SubjectTerms | Aneurysm, Dissecting - diagnostic imaging Aneurysm, Dissecting - mortality Aneurysm, Dissecting - surgery Aortic Aneurysm, Thoracic - diagnostic imaging Aortic Aneurysm, Thoracic - mortality Aortic Aneurysm, Thoracic - surgery Blood Vessel Prosthesis Implantation - methods Female Follow-Up Studies Hospital Mortality - trends Humans Incidence Male Middle Aged Pennsylvania - epidemiology Postoperative Complications - epidemiology Postoperative Complications - prevention & control Retrospective Studies Risk Assessment - methods Risk Factors Stroke - epidemiology Stroke - prevention & control Survival Rate - trends Time Factors Tomography, X-Ray Computed Treatment Outcome |
| Title | Aggressive Aortic Arch and Carotid Replacement Strategy for Type A Aortic Dissection Improves Neurologic Outcomes |
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