Rapid Reperfusion: Management Strategy of ATAAD with Cerebral Malperfusion

Cerebral malperfusion is a known complication of type A acute aortic dissection, which is linked to considerable perioperative mortality and morbidity. This article presents a case of Stanford acute type A aortic dissection (ATAAD) successfully managed by early percutaneous fenestration, transluminal angioplasty of the right carotid artery, and emergency central aortic repair of the ATAAD.The PatientA sixty-four-year-old man presented to the emergency department with a history of syncope followed by tonic-clonic seizures and dense left hemiplegia, without chest or back pain. Because of low GCS, urgent intubation was required. Five years earlier, the patient had undergone an abdominal aortic aneurysm repair, and he had been under annual surveillance for a 45 mm ascending aortic aneurysm. On a head and neck CT with a brain perfusion scan, a significant right MCA area and right frontal lobe infarct without hemorrhagic changes were visible along with evidence of ATAAD affecting the aortic arch and its branches (Figure 2). On the gated CT aortogram, an extensive ATAAD involving arch vessels was visible from the ascending aorta to the abdominal aorta (Figure 1). Both true and false lumens supplied blood to the brachiocephalic artery, and the right common carotid artery's flow was compromised.The ProcedureThe multidisciplinary team's immediate suggestions included percutaneous fenestration and transluminal angioplasty of the right common carotid artery, followed by an MR perfusion scan to reassess cerebral circulation. Through the right common femoral artery, a successful percutaneous fenestration procedure into the right common carotid artery was carried out, and a stent was successfully deployed (Figure 3).The patient experienced hemodynamic instability during MR imaging, necessitating an urgent pericardiocentesis, followed by prompt ATAAD central aortic repair with right femoro-femoral cardiopulmonary bypass. An antegrade cerebral perfusion via the brachiocephalic artery and hypothermic circulatory arrest at 24°C were used during the surgical procedure. By using the open distal approach, a supracoronary ascending aorta replacement and aortic valve resuspension procedure were performed. Recovery after surgery was difficult because of the patient's prolonged ventilation and acute kidney injury, which resolved within seven days. The patient was discharged home from stroke rehabilitation on postoperative day eighteen after full recovery from left hemiplegia.Discus