Combined Aortic Replacement And Stenting Of Cervicocerebral Arteries In Ascending Aortic And Arch Branches Dissection
Mikhail Gordeev, Vladimir Uspenskiy, Anna Loginova, Dmitry Zverev, Artem Bakanov, Vitaliy Volkov, Olga Irtyuga, Alexandr Naimushin, Olga Moiseeva.
Almazov Federal Medical Research Centre, Saint Petersburg, Russian Federation.
OBJECTIVE: In one third of patients with ascending aortic dissection it affects cervicocerebral arteries. This may increase risk of perioperative adverse neurologic events. The effect of hybrid approach, including ascending aortic replacement and preventive stenting of cervicocerebral arteries, remain to be evaluated.
METHODS: Between January 2010 and October 2016, a total of 42 consecutive patients (74% males, mean age 51.98±11.31 years) with ascending aortic dissection (67% acute) involving carotid arteries were operated on. All patients were divided into two groups: isolated ascending aortic replacement (group 1, 33 patients) and hybrid (group 2, 9 patients) - ascending aortic replacement with preventive stenting of dissected cervicocerebral arteries due to the true lumen collapse >70%.
RESULTS: The mean cardiopulmonary bypass (178.20±8.53 in group 1 vs. 182.75±15.89 in group 2), cross-clamp (127.43±7.01 vs. 129.00±13.26) and circulatory arrest times (32,07±14,27 vs. 26,00±11,53) did not differ significantly. Hemiarch repair was performed in 35 patients (83.3%), and there were no cases of total arch replacement. In 71% we used axillary artery cannulation, in 24% - femoral, and in 5% - ascending aortic cannulation. We used antegrade cerebral perfusion and moderate hypothermia in 77% and 50% of patients of groups 1 and 2, respectively, and deep hypothermia in other cases. Overall 30-day mortality was 7,1% (3 patients, 1 from group 1). Freedom from stroke was 86,7% in group 1 and 83,3% in group 2. We revealed a negative correlation of stroke with axillary artery cannulation (r = -0,463), and positive - with femoral cannulation (r = 0,411). We found insignificantly increased mortality (p = 0,05) and similar rate of stroke (p = 0,443) in group 2 when compared with group 1. (Image: cervicocerebral arteries before (A) and after (B) stenting).
CONCLUSIONS: Preventive stenting of cervicocerebral arteries in ascending aortic dissection is not associated with significant increase of the mortality and stroke rate in patients with initially affected aortic arch branches. In case of femoral cannulation such patients are at risk of adverse neurologic events.
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