Stroke after Acute Type A Dissection Repair Using Right Axillary Cannulation First Approach.
Academic Article
Overview
abstract
BACKGROUND: This study seeks to analyze the details of strokes following acute type A dissection repair (ATAD) using right axillary artery (RAX) first approach. METHODS: Consecutive 356 ATAD repairs from 2005 to 2022 were analyzed based on arterial cannulation site. Strokes were evaluated by head CT. RESULTS: The rate of RAX cannulation was 82.6% (N=294) with 38.2% of antegrade cerebral perfusion utilization, both of which had increased over the years. Non-RAX group had more cardiogenic shock (RAX: 16.3% vs. non-RAX: 37.1%, P<0.001), cerebral malperfusion (8.8% vs. 25.8%, P<0.001), and innominate artery dissection (45.9% vs. 69.2%, P=0.007). Eight patients died before undergoing a full neurological assessment. Overall stroke rate was 8.4% (N=30) which was lower in the RAX group (5.1% vs. 24.2%, P<0.001). All strokes were ischemic with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately following surgery (perioperative stroke) accounted for 70% (N=21/30) of cases. Strokes predominantly affected the right anterior circulation (Right-anterior, 80% vs. Left-anterior, 46.7% vs. Left-posterior, 26.7%, P=0.013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism: 33.3%, hypoperfusion: 42.8%, embolism+hypoperfusion: 14.3%, lacunar infarct: 10%) while the majority of postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale was 20.6±9.9, and modified Rankin score at discharge was 4.1±2.2. CONCLUSIONS: Majority of strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This is most likely due to unstable hemodynamics and dissection in the innominate artery or its downstream.
