Stroke After Acute Type a Dissection Repair Using Right Axillary Cannulation First Approach

Authors

Suguru Ohira, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York. Electronic address: suguru.ohira@wmchealth.org.Follow
Masashi Kai, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.Follow
Joshua B. Goldberg, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.Follow
Ramin Malekan, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.Follow
Vasiliki Gregory, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
Corazon de Pena, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
Kosuke Aoki, Department of Neurosurgery and Biochemistry, University of Miami, Miami, Florida.
Satoshi Egawa, Department of Neurology, Colombia University Irving Medical Center, New York, New York.
Steven L. Lansman, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.Follow
David Spielvogel, Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.

Author Type(s)

Faculty

DOI

10.1016/j.athoracsur.2023.11.028

Journal Title

The Annals of Thoracic Surgery

First Page

753

Last Page

760

Document Type

Article

Publication Date

4-1-2024

Department

Surgery

Abstract

BACKGROUND: This study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach. METHODS: A total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography. RESULTS: The rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2. CONCLUSIONS: Most strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels.

Recommended Citation

Ohira, S., Kai, M., Goldberg, J. B., Malekan, R., Gregory, V., Pena, C. d., Aoki, K., Egawa, S., Lansman, S. L., & Spielvogel, D. (2024). Stroke After Acute Type a Dissection Repair Using Right Axillary Cannulation First Approach. The Annals of Thoracic Surgery, 117 (4), 753-760. https://doi.org/10.1016/j.athoracsur.2023.11.028