Direct bilateral carotid artery cannulation can be better strategy for acute aortic dissection involving both carotid arteries

Cerebral Protection Strategies and Stroke in Surgery for Acute Type A Aortic Dissection

Background: Perioperative stroke remains a devastating complication in the operative treatment of acute type A aortic dissection. To reduce the risk of perioperative stroke, different perfusion techniques can be applied. A consensus on the preferred cerebral protection strategy does not exist. Methods: To provide an overview about the different cerebral protection strategies, literature research on Medline/PubMed was performed. All available original articles reporting on cerebral protection in surgery for acute type A aortic dissection and neurologic outcomes since 2010 were included. Results: Antegrade and retrograde cerebral perfusion may provide similar neurological outcomes while outperforming deep hypothermic circulatory arrest. The choice of arterial cannulation site and chosen level of hypothermia are influencing factors for perioperative stroke. Conclusions: Deep hypothermic circulatory arrest is not recommended as the sole cerebral protection technique. Antegrade and retrograde cerebral perfusion are today’s standard to provide cerebral protection during aortic surgery. Bilateral antegrade cerebral perfusion potentially leads to superior outcomes during prolonged circulatory arrest times between 30 and 50 min. Arterial cannulation sites with antegrade perfusion (axillary, central or carotid artery) in combination with moderate hypothermia seem to be advantageous. Every concept should be complemented by adequate intraoperative neuromonitoring.

Intraoperative nadir hematocrit as a poor outcome predictor after acute type A aortic dissection surgey

Acute type A aortic dissection is a life-threatening disease associated with high morbidity and mortality that requires urgent surgical intervention. Hemodilution is inevitable in cardiac operations performed with cardiopulmonary bypass, which leads to nadir hematocrit levels. Studies have shown that nadir hematocrit levels are associated with poor postoperative outcomes. The management strategy of intraoperative anemia in these operations is still controversial. Should we follow the patients with intraoperative low hematocrit values or should we transfuse them? In addition to intraoperative nadir hematocrit, cannulation strategies play an important role in early postoperative outcomes after aortic dissection surgery.