Surgical strategy and long-term outcomes of dissected carotid artery with false lumen thrombus in acute type A aortic dissection

Introduction

Acute type A aortic dissection (ATAAD) complicated with common carotid artery (CCA) involvement is not rare with an incidence of 15–24% (1,2), and this condition often results in cerebral malperfusion which has been reported in 6% to 15% of patients (3-5) and increases the risk of mortality and cerebral complications (3-9). Dynamic malperfusion with patent false lumen could be easily corrected after central aortic repair but static malperfusion (accompanied by false lumen thrombosis) is a troublesome condition and related to a poor early and long-term prognosis (9-12). How to deal with involved CCA with or without cerebral malperfusion is still controversial. Involved CCA and extended false-lumen thrombus is of special importance because: first, long thrombus could not be removed completely through single median sternotomy and conventional total arch replacement (TAR); second, there is no or only small reentry at the distal end of CCA so that thrombus tends to accumulate and cause true lumen occlusion again postoperatively; third, thromboembolism from false lumen might cause perioperative stroke. In this study, we compared two methods to treat the patients who suffered from ATAAD with involved CCA and extended false lumen thrombus. Carotid artery replacement (CAR) was performed as follow: CCA was exposed via an oblique cervical incision anterior to the sternocleidomastoid muscle and then a tunnel connecting mediastinum and the incision was made. The dissected CCA was resected at its bifurcation and thrombus in false lumen was removed in the meantime. One of the branches of the synthetic vascular graft was guided to the incision and anastomosed to CCA bifurcation by end-to-end. Reconstruction in situ (RIS) of supra-arch artery referred to that the vessel was detached at its proximal part and anastomosed to one branch of the prosthetic graft. In RIS procedure, false-lumen thrombus was removed as much as possible. The two techniques were illustrated in Figure 1. CAR could completely remove the lesions but need an extra incision and is time-consuming. RIS is simple and convenient but cause long thrombus to remain in false lumen. We present this article in accordance with the STROBE reporting checklist (available at https://cdt.amegroups.com/article/view/10.21037/cdt-23-464/rc).

Figure 1 Illustration of surgical techniques. (A) CAR; (B) RIS. CCA, common carotid artery; CAR, carotid artery replacement; RIS, reconstruction in situ.

Methods

Study population

The database of aortic dissection of Fuwai Hospital was reviewed. Among the consecutive patients who were surgically treated for ATAAD from March 2011 to December 2019 in Fuwai Hospital, patients suffering from dissected CCA with extended false-lumen thrombus were enrolled in the study as shown in Figure 2. Because there are disputes in the treatment, and there is no consensus in our center either, in terms of time, in the early-stage in-situ reconstruction was the main choice, after gradually recognizing the disadvantages, treatment options switched to a more active method. The two groups of patients were treated differently because of their chronological order. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The Institutional Review Board of Fuwai Hospital approved this retrospective study (No. 2022-1747), and the need for informed consent was waived for its retrospective nature.

Figure 2 Flow chart of inclusion and exclusion. ATAAD, acute type A aortic dissection; TAR, total arch replacement; FET, frozen elephant trunk; CT, computed tomography; CCA, common carotid artery.

Institutional definitions

Extended false-lumen thrombus was defined as a thrombus which extended to cervical region, frequently involving entire/subentire length of CCA. The features on computed tomography angiography (CTA) were shown in Figure 3A,3B. Cross-sectional thrombus area (TA) at the narrowest point and corresponding CCA area (CA) were measured on CTA through the integrated algorithm software (shown in Figure 3C). Ratio of cross-sectional TA was calculated as TA/CA. When patients had persistent hypotension (systolic blood pressure <90 mmHg) preoperatively, they were judge to have hemodynamic instability. All the malperfusion referred to radiographical manifestation whether there were clinical symptoms or not. Consciousness disorder refers to the disturbance of consciousness like delirium or drowsiness, with absence of focal infarction or bleeding on computed tomography (CT) scan. Permanent neurological deficit (PND) was defined as either focal or global deficits with permanence that newly emerged postoperatively, including ischemic or hemorrhagic stroke and coma. Temporary neurological deficit (TND) was defined as a short-term neurocognitive decline (including confusion, agitation, delirium, obtundation, or parkinsonism) which disappeared before discharge, without localized signs. Composite end point was defined as all kinds of postoperative neurologic deficits, including PND and TND. Operative mortality was defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital, and after 30 days during the same hospitalization subsequent to the operation. Complete remodeling of CCA referred to a normal lumen without thrombus or residual dissection.

Figure 3 The manifestation on CTA. (A) Cross-sectional image of occluded right common carotid artery; (B) three-dimensional reconstruction of supra-arch arteries; (C) cross-sectional thrombus area (yellow line) and corresponding common carotid artery area (red line) were measured at the narrowest point on CTA. CTA, computed tomography angiography.

Surgical techniques

Median sternotomy and cardiopulmonary bypass (CPB) were used. Axillary artery, femoral artery or combination of them were used as initial arterial cannulation site for CPB at surgeon’s discretion. After 2017, we modified cannulation strategy: when regional cerebral oxygen saturation (rSO₂) dropped below 55% or by 20% comparing with baseline (11,13), an extra arterial inflow route was established via cannulating the involved CCA (cervical incision). TAR with frozen elephant trunk (FET) were routinely used in our institution. A 4-branch prosthetic graft was used to replace aortic arch. The main trunk of the graft had a diameter of 28 or 30 mm (depending on the diameter of native aorta), and its branches were 10-10-8-8 mm. We used an 8-mm branch to reconstruct CCA. TAR and FET deployment were conducted as our previous description (14). CAR and RIS were performed as described in the introduction.

Follow-up

Data was obtained from each patient’s outpatient clinic document or by telephone contact. The survivors received radiographic follow-up by CTA. Survival, cerebrovascular accident and reintervention were investigated.

Statistical analysis

Data were presented as mean and standard deviation for continuous data conforming to normal distribution and as number (%) for categorical data. Continuous variables that didn’t conform to a normal distribution were demonstrated as median and interquartile range (IQR). Mean of two continuous normally distributed variables were compared by independent samples Student’s t-test. Comparison of categoric variables between groups was analyzed by likelihood ratio Chi-squared test or Fisher’s exact test. We used a composite end point (including PND and TND) and multivariate logistic regression analysis to investigate the effect of management of CCA on neurological outcomes. Based on previous research and clinical experience, factors that may affect neurologic deficit were included in multivariate analysis. Kaplan-Meier method was used for survival analysis and log-rank test was used to compare the difference on survival rate. A value of P<0.05 of two-sided test was considered significant. The data were analyzed by Stata (version 15.0, Stata Corp LP, College Station, TX, USA). No artificial intelligence was used in any of the processes of the study.

Results

Demographics and preoperative characteristics

Sixty-eight patients were enrolled in this study and allocated into two groups according to the management of involved CCA: CAR group (24 patients) and RIS group (44 patients). The mean age of patients was 47.8±8.8 years, with a male preponderance (80.9%). The mean duration from onset to operation was 54.4±63.9 hours. Preoperative consciousness disorder occurred in 3 (4.4%) patients and 4 (5.9%) patients had prior stroke. Six (8.8%) patients had Marfan syndrome who were confirmed by clinical history, physical examination and pathological diagnosis. Unilateral involvement of CCA was found in 62 (91.2%) patients and bilateral lesion occurred in 6 (8.8%) patients. Ratio of cross-sectional TA was 91.9±12.2 on average and this ratio was similar across the two groups (CAR vs. RIS, 95.8%±9.1% vs. 89.8%±13.3%, P=0.05). More patients in CAR group had completely occluded true lumen (CAR vs. RIS, 70.8% vs. 31.8%, P=0.002). The baseline data were demonstrated in Table 1.

Operative details

All the patients received TAR and FET. More patients in CAR group received femoral cannulation for initial CPB (CAR vs. RIS, 54.2% vs. 6.8%, P=0.001) and axillary + femoral cannulation was more frequently used in RIS group (CAR vs. RIS, 25.0% vs. 65.9%, P=0.001). Two patients in CAR group accepted CCA cannulation adding to femoral cannulation. More patients in CAR group received USCP from contralateral side of involved CCA (CAR vs. RIS, 83.3% vs. 50.0%, P=0.01). Selective cerebral perfusion (SCP) duration and cross-clamp duration were shorter in RIS group (CAR vs. RIS, 32.7±10.4 vs. 27.8±9.0 min, P=0.04 and 131.5±29.5 vs. 108.3±26.7 min, P=0.002). SCP flow rate, hypothermia circulatory arrest (HCA) duration and CPB duration were comparable between the two groups. Operative characteristics were demonstrated in Table 2.

Early outcomes

Five patients (7.4%) died within 30 days after operation. One patient died of cerebral hemorrhage and one patient died of brain herniation caused by massive cerebral infarction. Three patients died of multiple organ failure. Operative mortality was comparable between the two groups (CAR vs. RIS, 4.2% vs. 9.1%, P=0.65). Two patients in CAR group suffered from cerebral hemorrhage (one in frontal lobe, one in parietooccipital region). Six patients in RIS group were affected by cerebral infarction (five massive infarction, one focal infarction in basal ganglia region). The incidence of PND was similar across the two groups (CAR vs. RIS, 8.3% vs. 13.6%, P=0.70). No significant difference was found between the two groups with regard to TND (CAR vs. RIS, 16.7% vs. 20.5%, P=0.76). Similarly, there was no statistical difference in composite endpoints between the two groups (25.0% vs. 34.1%, P=0.43). Occlusion of CCA recurred in two patients in RIS group due to false-lumen thrombus. They received immediate CAR after the initial operation. One patient died of multiple organ failure and the other completely recovered. Among the survivors, 25 (56.8%) patients in RIS group had residual false-lumen thrombus at discharge. Other perioperative outcomes were showed in Table 3. In multivariate logistic regression, CAR was an independent protective factor of composite end point [odds ratio (OR) =0.03, 95% confidence interval (CI): 0.0–0.61, P=0.02]. Age was the only risk factor of composite end point (OR =1.34, 95% CI: 1.11–1.62, P=0.002, Figure 4).

Figure 4 Forest plot of CAR vs. RIS regarding postoperative neurological deficit. CAR, carotid artery replacement; RIS, reconstruction in situ; CA, carotid artery; AXA, axillary artery; FA, femoral artery; CCA, common carotid artery; SCP, selective cerebral perfusion; NT, nasopharyngeal temperature; ES, effect size; CI, confidence interval.

Follow-up results

Two patients were lost to follow-up and the median follow-up time was 40 (IQR, 24–69) months. Three patients in RIS group died during follow-up period. Two patients suffered from sudden cardiac death and one patient died of cancer. In survival analysis, we included the patients who died with 30 days postoperatively and follow-up time for them was recorded as 1 month. The overall survival rates at 1, 5, and 10 years postoperatively were 95.8%, 95.8%, and 95.8% in CAR group and 90.5%, 84.1%, and 76.4% in RIS group, respectively (P=0.22, Figure 5). No cerebrovascular accident and reintervention occurred in the whole cohort. All the grafts anastomosing to CCA bifurcation were patent.

Figure 5 Overall survival rate in both groups. RIS, reconstruction in situ; CAR, carotid artery replacement; CI, confidence interval.

For the patients who had residual false-lumen thrombus, 22 of them had at least one radiographic follow-up. Among them, complete remodeling occurred in 16 patients (72.7%). Six CCA in five patients demonstrated patent double lumen. The prognosis of these CCAs and a typical remodeling process on CTA were showed in Figure 6.

Figure 6 Prognosis of residual false-lumen thrombus in 22 patients who had radiographic follow-up. The numbers on the left of the vertical axis are patient numbers. The length of the line segment represents the duration of follow-up. The color of the line segment represents the duration of warfarin use. Different symbols represent the prognosis of false lumen. (A) False-lumen thrombus of right common carotid artery dissolved 3 months after surgery; (B) complete remodeling of right common carotid artery occurred 18 months after surgery in patient No. 16.

Discussion

In ATAAD, incidence of preoperative cerebral malperfusion was as high as 8% to 18% (3,7,15). The major goals of treatment for these patients were rescuing life and prevent brain complications. Unfortunately, the in-hospital mortality was as high as 26–56% and the incidence of postoperative neurological deficit ranged from 17% to 69% in the patients with preoperative symptomatic cerebral malperfusion (3,4,6,7). On the other hand, prolonged preoperative cerebral ischemic time was a major contributor to worse outcomes (16-19). For the above reasons, we did not perform open surgery for the patients with stroke or coma. In fact, because of our aforementioned strategy, this study had a selective bias and did not include patients with both long dissection with extensive false-lumen thrombus and preoperative neurologic deficit, the patients selected might already have a very efficient cerebral collateral flow. This is the difference between the present study and previous studies. Nevertheless, even without malperfusion, we believe that involved CCA with extensive false-lumen thrombus was of utmost importance, comparing with patent false lumen. Inoue et al. (9) reported that a thrombosed false lumen, especially when accompanied by an occluded CCA, resulted in worse outcomes regardless of preoperative neurologic symptoms. It is important to evaluate the strategies and outcomes of these patients because the risks of intra- and postoperative malperfusion still exist (11).

According to other reports and our experiences, there were three important matters should be paid attention to: initial canulation route, SCP and management of the dissected carotid artery. The optimal initial cannulation strategy remains controversial (10). Axillary artery, ascending aorta and femoral artery were all candidate sites for initial cannulation (2,11,20), but blood flow to brain might be limited via these cannulation sites (21-23). Patients maintained equivalent cerebral perfusion by collateral circulation via the circle of Willis preoperatively. But when CPB was established, the balance would be disrupted. Moreover, it was more difficult for nonpulsatile blood to flow through the fixed true-lumen stenosis (24). Intra-operative malperfusion might develop in these patients. So direct cannulation via involved CCA was advocated to restore brain perfusion as soon as possible (9,12,25-27). Furukawa et al. (11) introduced a method called quick cut-down technique to canulate CCA to gain rapid cerebral perfusion and other researchers reported similar method (9,12). In our opinion, monitoring in operation was important and could determine necessity of direct CCA cannulation. After 2017, we used cerebral oximetry monitoring to guide our cannulation strategy. Two patients received CCA cannulation to add an extra arterial inflow route and no malperfusion-related complications occurred. Of course, rSO₂ was an indirect technique and had deferred reaction for malperfusion. Furukawa et al. (11) used color-flow and pulse-wave Doppler by transcutaneous echo to detect cerebral perfusion. They only perform direct CCA cannulation when intraoperative disappearance of carotid flow was detected. It was a timely and sensitive evaluation of perfusion and could determine quick revascularization of involved branches. We failed to show a significant association between direct CCA cannulation and the outcome in present study because of fewer cases.

Selective cerebral perfusion is another important issue. Antegrade and retrograde SCP were both used in previous studies (2,9-12,20) and in most studies (9-12) bilateral antegrade SCP was more frequently used than unilateral route. In our study, we all used unilateral SCP on the basis of believing in adequate collateral circulation. For these patients, either of two SCP routes was used by surgeon’s judgement: from contralateral side or ipsilateral side of involved CCA. We compare pump pressure between the two routes and no significant difference was found. It was certified that a nonpulsatile blood with a flow rate of 5 mL/kg/min or more could flow through the stenosis of true lumen during HCA phase. In multivariate logistic regression analysis, SCP route was not a risk factor of postoperative neurologic deficit. Indeed, bilateral SCP was more reliable in theory and its necessity needed to be confirmed in future studies.

TAR is a standard approach for patients with dissected arch in Fuwai Hospital because we had younger patients than western countries. Management of involved CCA is a critical step but consensus on optimal procedure has not been reached yet. There was no direct comparison between different strategies. Charlton-Ouw et al. (2) reported a rate of postoperative stroke as 14.6% in 43 patients whose involved CCA were not managed. This rate was higher than that in Sultan and colleagues’ study (12). For involved CCA with thrombosed false lumen, most centers performed CAR with a quite low rate of postoperative neurological deficit (9,12,20). They did so for the following reasons: first, to revascularize the involved vessel and restore cerebral perfusion; second, to eradicate thrombus from false lumen and avoid thromboembolism event. After 2017, our surgical strategy switched from RIS to CAR for involved CCA with extended false-lumen thrombus. In terms of surgical process, CAR needed more time spent as showed in this study: SCP duration and cross-clamp duration in CAR group were significantly longer than those in RIS group. In terms of outcomes, the two groups had quite different operative mortality but no statistical significance was found. The small sample is probably driving the nonsignificant P value, probably a beta error from small number of patients exists. Actually, PND in CAR group manifested as hemorrhagic stroke that could not be simply attributed to implementation of CAR. On the contrary, PND in RIS group demonstrated as ischemic stroke which was more reasonable in pathophysiology. After adjusting confounders potentially related to outcome, CAR was an independent protective factor of composite end point. Furthermore, incomplete thrombus removal might result in recurrent occlusion of true lumen, as the two patients who received unplanned CAR in RIS group. Based on these results, we have reason to believe CAR could thoroughly remove thrombus and reduce the incidence of postoperative neurologic deficit.

Fortunately, we obtained quite satisfying long-term results, whether in CAR group or RIS group. The overall survival rate was similar between the two groups and better than that in previous studies (9,12). The survival rates at 10 years of the two groups were quite different (96% vs. 76%) but statistical significance was not found. This could be attributed to the small sample size. At discharge, 56.8% of the patients in RIS group had residual false-lumen thrombus and this rate was similar to Charlton-Ouw’s study (2). Among the 22 patients who had radiographic follow-up, 90.9% of them had complete reabsorption of thrombus mostly after anticoagulant therapy and 72.7% of them had complete CCA remodeling. This good prognosis of CCA may contribute to low rate of cerebrovascular accident and reintervention in RIS group. It can be concluded that the risks of death and neurological deficit mainly existed in perioperative period from the above results. The same conclusion was drawn by other investigators (2,12,27). Although complete CCA remodeling occurred in two patients without warfarin, we firmly believe it is necessary to accept warfarin treatment for 6 months, as Charlton-Ouw et al. and Laser et al. proposed (2,27).

Limitations

This study has some limitations. First, it is a retrospective study and we didn’t include patients with symptomatic cerebral malperfusion so that selection bias did exist. Second, the duration from onset to operation in our study was obviously long so survivor bias might exist. Third, there was no adequate information to evaluate internal carotid artery that was important for prognosis. Fourth, we had a relatively small sample size because we excluded the patients suffered stroke or coma preoperatively and the patients who had not severely involved CCA. The small sample size limited multivariate analysis and more comparative analysis and a beta error did exist.

Conclusions

CAR was an effective technique to manage involved CCA with extended false-lumen thrombus and could protect patients from postoperative neurological deficit than RIS. Patients receiving RIS were at risk of recurrent true-lumen occlusion after operation. Most residual thrombus in false lumen could be reabsorbed after anticoagulant therapy. The patients could have a satisfying long-term outcome after survived from perioperative period.

Acknowledgments

We thank Yang Lei (PhD, Peking University Cancer Hospital) for the help on statistical analysis. No AI tools were applied in the writing of a manuscript, production of images or graphical elements of the paper, or in the collection and analysis of data.

Funding: This study was supported by Beijing Natural Science Foundation (No. Z210012).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://cdt.amegroups.com/article/view/10.21037/cdt-23-464/rc

Data Sharing Statement: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-23-464/dss

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-23-464/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-23-464/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The Institutional Review Board of Fuwai Hospital approved this retrospective study (No. 2022-1747), and the need for informed consent was waived for its retrospective nature.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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