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.