Aortic Arch and Root Reconstruction in Chronic Type a Aortic Dissection with Impaired Cerebral Blood Flow due to Malperfusion of the Bilateral Vertebral Arteries and Occlusion of the Posterior Communicating Arteries

Case Report

J Cardiovasc Disord. 2014;1(2): 2.

Aortic Arch and Root Reconstruction in Chronic Type a Aortic Dissection with Impaired Cerebral Blood Flow due to Malperfusion of the Bilateral Vertebral Arteries and Occlusion of the Posterior Communicating Arteries

Tsuneo Ariyoshi*, Mizuki Sumi and Masayoshi Hamawaki

Department of Cardiovascular Surgery, National Hospital Organization Nagasaki Medical Center, Japan

*Corresponding author: Tsuneo Ariyoshi, Department of Cardiovascular Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Omura Nagasaki 856-8562, Japan

Received: September 14, 2014; Accepted: November 07, 2014; Published: November 10, 2014

Abstract

Cerebral malperfusion is a life-threatening complication of type A acute aortic dissection. Even in the chronic phase, special care is required in some patients with complicated brain blood flow patterns to avoid intraoperative cerebral malperfusion. The present report describes the case of a patient with chronic type A aortic dissection and complex impaired cerebral blood flow, in which selective antegrade cerebral perfusion using a branch graft attached to left subclavian artery anastomosed via a double-barrel technique and reconstruction of arch vessels resulted in a successful outcome without any new neurological deficits. The case presentation is followed by a discussion of the relevant published literature.

Keyword: Aortic Dissection; Perfusion; Brain

Introduction

Cerebral malperfusion is a life-threatening complication of type A acute aortic dissection and has an impact on the indications for surgical intervention [1,2]. However, even in the chronic phase, special care is required to avoid ischemic cerebral damage in some patients with complicated brain blood flow patterns caused by preoperative cerebral malperfusion.

Case Report

A 67-year-old man experienced sudden onset of chest pain and was transferred to our hospital. Although Computer Tomography (CT) showed A type an aortic dissection, emergent surgery was postponed, because he was very drowsy and had left hemiplegia at the time of admission. CT imaging showed early signs of brain infarction [3] in the territory of the right middle cerebral artery as well as cerebral malperfusion secondary to obliteration of right carotid artery. The patient needed mechanical ventilation in his early clinical course but was weaned from the ventilator on hospital day 10 and eventually recovered from severe consciousness disorder. The left incomplete paralysis remained, but he could walk with a stick at the time of the first discharge. Two months later, elective aortic root and total arch replacement was planned to address progressive dilation of the aortic root and severe aortic valvular regurgitation. CT and preoperative Magnetic Resonance (MRI) showed a unique cerebral perfusion pattern. The right cerebral hemisphere had become atrophic because of the preceding infarction. Dissection was present in the bilateral subclavian arteries and in the right common carotid arteries, and the bilateral vertebral arteries were branched from the false lumen of the subclavian arteries (left side dominant). Further, the posterior communicating arteries were totally occluded (Figure 1). Therefore, a specific intraoperative perfusion technique was planned for brain protection. After a median sternotomy, Cardio Pulmonary Bypass (CPB) was established by extracting blood from the right atrium and rerouting it to the right axillary and femoral arteries with left ventricular venting. The patient was cooled to 20°C, and the ascending aorta was cross-clamped and transected. After injection cold cardioplegia solution, Bentall operation was performed with a composite valved graft during systemic cooling. After aortic root replacement, circulatory arrest and Selective Antegrade Cerebral Perfusion (SCP) was begun through the right axillary artery perfusion by clamping the innominate artery. The aortic arch was opened, and a 12-Fr SCP balloon cannula was inserted into the true lumen of the left common carotid artery and the left subclavian artery. To preserve enough blood flow to the left vertebral artery through the false lumen, the left subclavian artery was immediately attached to a free 8-mm branch graft using a double-barrel anastomosis technique, and the SCP balloon cannula was then re-inserted into this graft and perfused. The multi-branched arch graft was anastomosed with the distal arch for arch reconstruction, antegrade aortic perfusion was re-started using a branch graft, and rewarming was initiated. After the anastomosis between the arch graft and Bentall's graft, the crossclamp of the arch graft was removed under SCP perfusion, and the heart was restarted (Figure 2). Finally, the left common carotid artery, innominate artery and the branch graft attached to the left subclavian artery were reconstructed with branch grafts. Regional brain oxygen saturation (rSO2) was measured with an optical spectrophotometer attached to the bilateral forehead of the patient throughout the operation to monitor cerebral circulation, and no abnormal change in this value was observed. Postoperative recovery of the patient was good, and there was no neurological complication. No remarkable changes were detected when comparing preoperative and postoperative brain CT images.

Citation: Elgendy IY, Choi C and Bavry AA. Aortic Arch and Root Reconstruction in Chronic Type a Aortic Dissection with Impaired Cerebral Blood Flow due to Malperfusion of the Bilateral Vertebral Arteries and Occlusion of the Posterior Communicating Arteries. J Cardiovasc Disord. 2014;1(1): 2. ISSN: 2379-7991