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J Thorac Cardiovasc Surg 2005;129:1190-1191
© 2005 The American Association for Thoracic Surgery

Brief Communications

Cerebral malperfusion in acute type A dissection: Direct innominate artery cannulation

Genichi Sakaguchi, MD, PhD*, Tatsuhiko Komiya, MD, Nobushige Tamura, MD, PhD, Shogo Obata, MD, Shinji Masuyama, MD, Chieri Kimura, MD, Taira Kobayashi, MD

Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan.

Received for publication August 6, 2004; revisions received September 1, 2004; accepted for publication September 3, 2004.

* Address for reprints: Genichi Sakaguchi, MD, Department of Cardiovascular Surgery, Kurashiki Central Hospital, Miwa, Kurashiki City, Okayama, 710-8602, Japan (E-mail: gs8722{at}kchnet.or.jp).


Figure 1
Komiya, Tamura, Masuyama, Kimura, Kobayashi, Obata, Sakaguchi (left to right)


Brain ischemia caused by malperfusion of major arch vessels in acute type A dissection is associated with a significantly higher risk of mortality. This report describes an urgent introduction of the selective cerebral perfusion immediately after establishment of cardiopulmonary bypass followed by total arch replacement in a case of acute type A dissection complicated with preoperative cerebral ischemia.

Clinical summary

A 56-year-old man was transferred to our hospital after presenting with an abrupt loss of consciousness. At the time of admission, the patient was lethargic, although easily arousable, and responded to his name being called. His consciousness level was assessed at 14 on the Glasgow Coma Scale. His initial brain computed tomographic (CT) scan disclosed neither acute hemorrhage nor obvious ischemic changes. According to the neurologic status and CT findings, it was speculated that he did not have a cerebral infarction, despite the right-sided hemispheric hypoperfusion.

Duplex ultrasonography showed compression of the true lumen by the false lumen in the right carotid artery (Figure 1). A contrast-enhanced CT scan revealed a type A dissection extending from the sinotubular junction down to the bilateral common iliac arteries.


Figure 1
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  		Figure 1. Duplex carotid echocardiogram showing compression of the true lumen by the false lumen in the right carotid artery.

 
An emergency operation was performed 2 hours after admission. Near-infrared optical spectrophotometer probes were attached to the bilateral forehead of the patient to monitor regional cerebral oxygenation (rSO2) throughout the operation (Figure 2). rSO2 in the right side of the forehead was 21%, and that in the left side of the forehead was 50%.


Figure 2
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  		Figure 2. Changes in rSO2 during the procedure. CPB, Cardiopulmonary bypass; SCP, selective cerebral perfusion.

 
After cardiopulmonary bypass was established with the right femoral artery used for inflow and the superior and inferior venae cavae for drainage, rSO2 was still at a critically low level on the right side. The innominate artery was crossclamped proximally and transected. A 14F perfusion catheter was inserted in the true lumen of the innominate artery, and partial selective cerebral perfusion was started. The rSO2 in the right side of the forehead immediately recovered to the level of the left side (50%). The patient was cooled (25°C), and the systemic perfusion through the femoral artery was discontinued. An intimal tear was identified in the aortic arch. Perfusion catheters were inserted in the left common carotid artery and the left subclavian artery for total cerebral perfusion. The total arch was replaced with a tube graft with 4 limbs, and selective cerebral perfusion was terminated. The patient was discharged on postoperative day 19 without any neurologic deficits.

Discussion

Preoperative neurologic deficit is highly associated with operative mortality in surgical treatment for acute type A dissection.1 Fann and colleagues2 reported that arch vessel occlusion caused stroke in 5.5% of patients with acute type A dissection. The right carotid artery is most commonly involved, and this often occurs in conjunction with innominate artery dissection.2 In our case the preoperative cerebral malperfusion resulted from extension of the dissection into the right carotid artery with compression of the true lumen. The axillary artery has been proposed as an inflow of cardiopulmonary bypass in the operation for acute type A dissection to avoid malperfusion instead of the femoral artery3; however, the direct innominate artery cannulation is a less time-consuming (easy) and reliable method to restore cerebral perfusion in such a case with cerebral malperfusion. Fukada and coworkers4 reported an intraoperative cerebral malperfusion caused by retrograde femoral perfusion that had been successfully treated in the same method.

Because it was speculated that the patient did not have cerebral infarction, despite the right-sided hemispheric hypoperfusion in this case, the more rapid restoration of cerebral perfusion was expected to result in less cerebral damage.

References

  1. Pansini S, Gagliardotto PV, Pompei E, Parisi F, Bardi G, Castenetto E, et al. Early and late risk factors in surgical treatment of acute type A aortic dissection. Ann Thorac Surg. 1998;66:779-784.[Abstract/Free Full Text]
  2. Fann JI, Sarris GE, Miller DC, Mitchell S, Oyer PE, Stinson EB, et al. Surgical management of acute aortic dissection complicated by stroke. Circulation 1989;80(suppl I):I257-I263.
  3. Sabik JF, Nemeh H, Lytle BW, Blackstone EH, Gillinov AM, Rajeswaran J, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg. 2004;77:1315-1320.[Abstract/Free Full Text]
  4. Fukada J, Morishita K, Kawaharada N, Yamauchi A, Hasegawa T, Satsu T, et al. Isolated cerebral perfusion for intraoperative cerebral malperfusion in type A aortic dissection. Ann Thorac Surg. 2003;75:266-268.[Abstract/Free Full Text]



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