Discussion
Surgical repair for ATAAD in presence of CM due to carotid artery obstruction may often be dismal, as prolonged cerebral perfusion deficit may lead to a disabling ischemic stroke, with major implications on patient’s quality of life or may even be futile, as patients are of high risk of developing cerebral edema and herniation syndrome or major cerebral hemorrhage during surgery. Further, ATAAD patients with CM often present with major neurological symptoms and/or in a comatose state questioning surgical candidacy.
A recent study by Fukuhara et al. reviewed 80 ATAAD patients with CM(1). Only 74% of those patients underwent open surgical repair. In-hospital mortality was 40% in the whole cohort and 19% in the subgroup of patients who received surgical management, with neurological death being the major cause for mortality in those patients. In-hospital mortality was 100% in patients with ICA occlusion as compared to 21% in patients with CCA occlusion. Hence, optimal brain salvage strategies in ATAAD patients with CM – and especially ICA occlusion - are still unclear.
From landmark stroke studies it is known that early recanalization of distal ICA occlusion is beneficial regarding clinical outcome(2). However, endovascular carotid recanalization in the setting of ATAAD is still being reported only anecdotally. Heran et al recently presented the case of an ATAAD patient with right CCA occlusion who underwent successful percutaneous carotid stenting prior to surgical repair with excellent neurological outcome(3). However, to the authors’ knowledge, the here presented case is the first report regarding successful percutaneous recanalization of an ICA occlusion in the setting of an ATAAD prior to open surgical aortic repair with excellent clinical outcome after three year follow-up, including almost full neurological recovery.
It is important to note, that the limiting outcome factor in most ATAAD patients with CM is the duration of cerebral perfusion deficit. Hence, a staged approach may be most promising in cases where time to restoration of cerebral perfusion can be significantly shortened by immediate endovascular carotid recanalization as compared to immediate surgical repair.
In conclusion, percutaneous endovascular treatment of carotid occlusion in ATAAD patients presenting with CM in order to restore cerebral perfusion prior to surgical aortic repair may improve clinical outcome and reduce neurologic sequelae in selected patients.