Single-center Retrospective Clinical Research Of Surgical Treatment Of Type A Aortic Dissection With Carotid Occlusion

Objective: Type A aortic dissection(TAAD)can be extended to the blood vessels above the arch,the management of cerebral malperfusion caused by occlusion or severe stenosis of the left common carotid artery(LCCA)or right common carotid artery(RCCA)has always been a controversial topic.Although there have been many reports that cerebral malperfusion can be restored by aorta-carotid bypass graft,the causes of true lumen occlusion of the carotid artery and the specific methods of the aorta-carotid bypass are still not clear.The aim of this study is mainly to analyze and evaluate the classification of true lumen occlusion of the carotid artery for TAAD patients with high risk of stroke and in-hospital mortality and provide the best operation method for bypass grafting according to different types.Methods: We investigated 425 consecutively TAAD patients who underwent central aortic repair between May 2010 and April 2018 and analyzed the degree of true lumen stenosis of carotid artery retrospectively.Cerebral perfusion was found in 53 patients due to carotid artery occlusion or severe stenosis,including 23 patients with bilateral carotid artery involvement,30 patients with unilateral carotid artery involvement,37 patients with static obstruction and 16 patients with dynamic obstruction.TAAD repair comprised hemi-(n = 13)or total(n =40)arch replacement in combination with extra-anatomic aorta-carotid bypass(n=7),aortic valve repair(n = 1)or replacement(n = 28)and coronary bypass(n = 1).In 7 patients with aorta-carotid bypass,there were 5 affected carotid arteries that were anastomosed by end-to-side and3 were anastomosed by end-to-end.In order to recover cerebral perfusion early,the extra-anatomic aorta-carotid bypass should be established before the operation begins,or established when the oxygen saturation is found not to rise or decrease during the operation.Carotid arterial ultrasound(CDU)can be used to observe dynamic involvement of carotid arteries dissection through multiple sections and classify them.Results: Aortic-carotid artery bypass grafting was performed in 7patients,including 3 patients with end-to-end anastomosis,3 patients with end-to-side anastomosis,and 1 patient with right carotid artery end-to-side anastomosis combined with left carotid artery end-to-end anastomosis.No obvious nerve defect was found in the 7patients postoperatively.Stroke rates by extent of arch replacement were41.7%(5/12),35.5%(11/31)and 0(0/7)(p=0.048)for hemi-arch,total arch,and extra-anatomic aorta-carotid bypass,respectively.The postoperative mortality rates were 25.0%(3/12),19.3%(6/31)and14.3%(1/7)(p=0.844),respectively.Conclusion: According to the different types of carotid occlusion,choosing the corresponding operative method can make the surgical treatment more targeted,more convenient and more likely to reduce the incidence of postoperative stroke.