Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection—Single Centre Experience

Abstract

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1–2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25–28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/− 56.874 min, the mean aortic cross-clamp time was 114.775 +/− 34.602 min, and the mean cerebral perfusion time was 37.837 +/− 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418–9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25–28 °C.

Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection

“…Aortic cross-clamp time was not investigated, and neuroprotective strategies such as anterograde cerebral perfusion were not associated with de novo NCs [2]. We reported in a previous study that bilateral selective anterograde cerebral perfusion over 40 min is a risk factor for new postoperative ischemic stroke [8]. Permanent neurological dysfunction was associated with longer operation time, while increasing hypothermic circulatory arrest was associated with temporary neurologic dysfunction, in a study of 501 patients with aortic arch surgery [27].…”

“…Ischemic stroke is the most clinically important NC, and we reported a 24.8% postoperative incidence in a previous study [8]. Spinal cord ischemia (SCI), hypoxic-ischemic encephalopathy (HE), and postoperative delirium (PD) are severe complications, but there are scarce data regarding their postoperative incidence after emergency surgery for ATAAD.…”

Investigation of the Association between Bilateral Selective Anterograde Cerebral Perfusion and Postoperative Ischemic Stroke in Obese Patients with Emergency Surgery for Acute Type A Aortic Dissection

“…Exclusion criteria: (1) patients with hemorrhagic stroke documented on computed tomography (CT) scans before admission who were not candidates for surgery; (2) pa tients with ischemic stroke documented on computed tomography (CT) scans before ad mission and severe neurological dysfunction who were not candidates for surgery; (3 patients who died in the operating room or within the first 48 h after intensive car Despite advances in strategies for brain protection, the incidence of neurological complications in these patients is high and ranges from 17 to 48% [7][8][9]. One of the most dreaded neurological complications regarding mortality and morbidity is ischemic stroke, with an incidence of up to 24.8% [10].…”

“…Despite advances in strategies for brain protection, the incidence of neurologica complications in these patients is high and ranges from 17 to 48% [7][8][9]. One of the mos dreaded neurological complications regarding mortality and morbidity is ischemic stroke with an incidence of up to 24.8% [10].…”

Influence of Lavender Essential Oil on the Physical and Antibacterial Properties of Chitosan Sponge for Hemostatic Applications

“…During surgical procedures, excessive bleeding disrupts the patient's hemodynamics, prolongs the duration of the operation, and elevates the risk of infection from transfusions. These complications significantly contribute to the escalation of healthcare expenses and pose a life-threatening danger to the patient [7][8][9][10]. Therefore, to mitigate the risk of complications and reduce the chances of morbidity and mortality associated with a hemorrhage, it is crucial to use an effective hemostatic agent that can promptly achieve bleeding control [11][12][13].…”