Back to 2015 Masters Day Overview

OBJECTIVES
Operative management and intraoperative cerebral perfusion strategies in patients with an almost complete occlusion of the aortic arch or the ascending aorta remain a challenge.
We discuss multidisciplinary and surgical management options in patients with neurological complications of an acute aortic dissection.
METHODS (CASE DESCRIPTION)
A 64-year-old woman presented with acute severe chest pain. She was hypertensive, with no significant medical history. A CT scan confirmed an acute Stanford type A aortic dissection limited to the ascending aorta and arch the ascending aorta had near complete false lumen thrombosis with pin-hole flow in the true lumen due to extensive intra-mural haematoma. Echocardiography confirmed a competent valve and a small pericardial effusion. On starting labetalol infusion the patient developed a dense hemiparaesis and paraesthesia. As soon as the blood pressure increased within minutes the patient made a full neurological recovery.
RESULTS
The patient underwent emergency repair of aortic dissection. The cannulation and perfusion strategy were challenging as cerebral perfusion was tenouous. Cannulation was via an 8mm graft anastomosed to the right axillary artery. It was not possible to clamp the ascending aorta as it was burgeoning with thrombus. The patient was cooled to 15ºC. In steep Trendelenberg position the circulation was arrested, retrograde cerebral perfusion commenced and the ascending aorta incised and then excised. The aortic arch was excised obliquely, as much thrombus material as possible from the false lumen into the great vessels was retrieved followed by interposition Dacron graft placement. The patient had an uncomplicated recovery with no neurological sequlae and remains well at 6-month follow-up.
CONCLUSIONS
We discuss different intraoperative cerebral perfusion strategies especially in patients with an almost complete occlusion of the aortic arch and ascending aorta. We also discuss multidisciplinary management options in patients with neurological complications of an acute aortic dissection.