Diagnosis and Management of Cerebral Malperfusion Phenomena During Aortic Dissection Repair by Transesophageal Doppler Echocardiographic Monitoring

Coletti, Giuseppe; Torracca, Lucia; Canna, Giovanni La; Sebastiano, Piero; Fucci, Carlo; Berra, P; Alfieri, Ottavio

doi:10.1111/j.1540-8191.1996.tb00062.x

Cited by 17 publications

(6 citation statements)

References 5 publications

(2 reference statements)

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“…Coletti et al assessed the arch flow with TEE. 60) The TEE can visualize each of three arch branches and is helpful for identifying the mechanism of malperfusion. 61) …”

Section: Cerebral Malperfusionmentioning

confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.Keywords: aortic dissection, malperfusion, complication, echocardiography A cute type A aortic dissection (AAAD) not only causes sudden death at the time of onset but leads to various life-threatening complications. In spite of improved diagnostic imaging and surgical strategies, in-hospital mortality is still high, and patients who have survived often suffer from sequelae that make subsequent quality of life poor. This article is aimed to review the latest literature and ideas to seek the best possible way to minimize undesirable results.Various complications of AAAD caused by separation of the aortic wall to outer and inner layers are summarized as three categories: 1) aortic rupture due to disruption of the outer layer; 2) malperfusion caused by the inner layer, that is, the intimal flap; and 3) aortic regurgitation by a deformed aortic valve, leading to acute heart failure. Approximately 20% of patients instantaneously die due to aortic rupture, 1) and 1 to 2% of the remaining patients die every hour unless appropriately treated. 2) Although surgical outcomes are gradually improving, in-hospital mortality of surgical patients (repair on the aortic root to the arch) in 2009 was as high as around 10%, according to the Japanese database. 3) For the further improvement of outcomes, problems should be solved in each of preonset, pre-hospital, and in-hospital stages. In this review, the latter two stages are discussed first, since most of the literature focuses on these stages. After that, the issue of pre-onset stage, i.e., prevention is discussed. DelayeD DiagnosisIn consideration of the natural history of AAAD, the "chain of onset-to-sur...

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“…Coletti et al assessed the arch flow with TEE. 60) The TEE can visualize each of three arch branches and is helpful for identifying the mechanism of malperfusion. 61) …”

Section: Cerebral Malperfusionmentioning

confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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“…This procedure, however, is associated with a significant risk of emboli from atherosclerotic plaque or thrombi from the iliofemoral arterial wall and abdominal aortic wall being carried to either the brain or heart by means of retrograde perfusion. 3,4 Femoral arterial perfusion can result in unsatisfactory perfusion to the proximal vital organs in cases of rupture, and malperfusion can occur in cases of aortic dissection. 5 Moreover, when the open proximal method of repair is used during circulatory arrest, other problems may arise from femoral cannulation, including a restricted time of circulatory arrest to the brain and difficulties in deairing from the arch branches and the proximal ascending aorta.…”

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confidence: 99%

Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: Preliminary experience in 26 patients

Neri

Massetti

Barabesi

et al. 2002

The Journal of Thoracic and Cardiovascular Surgery

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“…As this provides retrograde flow, it carries the risk of malperfusion in dissection patients and cerebral embolization of plaques in patients with atheromatous disease. Other routes of arterial cannulation have therefore been explored 3,4 . Access to the axillary artery or left subclavian artery, however, requires dissection and exposure to the areas otherwise not required 4,5 .…”

Section: Commentmentioning

confidence: 99%

“…Traditionally, cardiopulmonary bypass in this setting has been established via the femoral vessels through a groin incision 2 . This, however, produces retrograde flow and may lead to preferential perfusion of the false lumen in patients with aortic dissection or potentially dislodge atheromatous plaques from diseased aorta resulting in cerebral embolization 3,4 . Alternative cannulation sites for antegrade flow include the axillary artery, left subclavian artery and left common carotid artery 4–6 .…”

Section: Introductionmentioning

confidence: 99%

Central Cannulation Through a Standard Left Thoracotomy for Surgery on the Descending Thoracic Aorta

2006

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Surgery on the descending thoracic aorta is often performed with hypothermic cardiopulmonary bypass established via the femoral vessels. This, however, produces retrograde flow, which may potentially dislodge atheromatous debris from a diseased descending aorta or results in malperfusion due to cannulation of the false lumen in patients with descending aortic dissection. In view of this, we have described a technique of central cannulation of the ascending aorta and main pulmonary artery, established via a standard left thoracotomy, providing antegrade flow and limiting the cerebral ischemic time.

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Diagnosis and Management of Cerebral Malperfusion Phenomena During Aortic Dissection Repair by Transesophageal Doppler Echocardiographic Monitoring

Abstract: We recommend continuous intraoperative TEE to monitor aortic arch flow during these operations. This allows immediate detection of cerebral malperfusion and prompt action can be taken to prevent irreversible brain damage.

Cited by 17 publications

References 5 publications

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: Preliminary experience in 26 patients

Central Cannulation Through a Standard Left Thoracotomy for Surgery on the Descending Thoracic Aorta

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