Authors
Mironenko V.A., Garmanov S.V., Mamilov M-B.T., Darvish N.A., Ismailov S.S., Fedorov N.V.
Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow
Abstract
A clinical case of surgical treatment of a 50-year-old patient with acute type A aortic dissection complicated by severe cerebral malperfusion and extension of the dissection into the brachiocephalic arteries is presented. Multislice CT revealed dissection of the brachiocephalic trunk with false lumen thrombosis, stenosis of the right common carotid artery, critical stenosis and false lumen thrombosis of the left common carotid artery, as well as involvement of the left subclavian artery. Given the high risk of perioperative cerebral ischemia, the operation was initiated with branch-first reconstruction of the brachiocephalic arteries using a trifurcated graft. After restoration of controlled cerebral perfusion, replacement of the ascending aorta and aortic arch was performed under adaptive cerebral perfusion. Cardiopulmonary bypass time – 232 min, cross-clamp – 101 min, and circulatory arrest – 36 min. The postoperative course was complicated by respiratory and renal failure requiring hemodialysis. The patient was discharged on postoperative day 30 in satisfactory condition.
Keywords: аcute type A aortic dissection, cerebral malperfusion, branch-first, adaptive cerebral perfusion, brachiocephalic arteries, aortic arch surgery.
References
1. Sun J, Xue C, Zhang J, et al. Extra-anatomic revascularization and a new cannulation strategy for preoperative cerebral malperfusion due to severe stenosis or occlusion of supra-aortic branch vessels in acute type A aortic dissection. Heliyon. 2023; 9(7): e18251. doi: 10.1016/j.heliyon.2023.e18251.
2. Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. J Am Coll Cardiol. 2022; 80(24): e223-e393. doi: 10.1016/j.jacc.2022.08.004.
3. Wang C, Zhang L, Li T, et al. Surgical treatment of type A acute aortic dissection with cerebral malperfusion: a systematic review. J Cardiothorac Surg. 2022; 17(1): 140. doi: 10.1186/s13019-022-01894-8.
4. Gomibuchi T, Seto T, Naito K, et al. Strategies to improve outcomes for acute type A aortic dissection with cerebral malperfusion. Eur J Cardiothorac Surg. 2021; 59(3): 666-673. doi: 10.1093/ejcts/ezaa376.
5. Su CH, Qin W, Chen W, et al. Surgical management of acute type A aortic dissection in complicated cases: experience with branch-first aortic arch replacement technique. Chin Med J (Engl). 2021; 134(8): 978-980. doi: 10.1097/CM9.0000000000001436.
6. Kemp U, Zhu A. Can a “branch-first” approach to aortic arch replacement be safely utilized in Stanford type A acute aortic syndromes? Interdiscip Cardiovasc Thorac Surg. 2023; 37(5): ivad172. doi: 10.1093/icvts/ivad172.
7. Mironenko VA, Averina TB, Shundrov AS, et al. Device for extracorporeal circulation and method for its assembly. Russian Federation patent № 2654776 C1. Published May 22, 2018. (In Russ.)
8. Mironenko VA, Kokoev MB, Garmanov SV, et al. Method of temporary subclavian-subclavian shunting in restricted blood flow through the brachiocephalic trunk. Russian Federation patent №2704235 C1. Published October 24, 2019. (In Russ.)
9. Garmanov SV, Soborov MA, Khizriev DA, Mironenko VA. Cerebral protection in aortic arch surgery: between the past and the future. Russian Journal of Thoracic and Cardiovascular Surgery. 2022; 64(6): 584-595. (In Russ.) doi: 10.24022/0236-2791-2022-64-6-584-595.
10. Mironenko VA, Garmanov SV, Chegrina LV, et al. Use of temporary arterial shunt in surgery of dissection of the aorta and brachiocephalic arteries. Angiol Sosud Khir. 2021; 27(4): 80-93. (In Russ.) doi: 10.33529/ANGIO2021419.
11. Friess JO, Beeler M, Yildiz M, et al. Determination of selective antegrade perfusion flow rate in aortic arch surgery to restore baseline cerebral near-infrared spectroscopy values: a single-centre observational study. Eur J Cardiothorac Surg. 2023; 63(4): ezad047. doi: 10.1093/ejcts/ezad047.
