Congenital Anomalies of the Aortic Arch in Acute Type-A Aortic Dissection: Implications for Monitoring, Perfusion Strategy, and Surgical Repair

OBJECTIVE:

To assess whether management of acute Stanford
type-A aortic dissection differs in patients with congenital anomalies
of the aortic arch compared with standard institutional practice.

DESIGN:

Retrospective analysis of all consecutive patients from 2001 through 2011.

SETTING:

Quaternary referral center for surgical management of thoracic aortic disease.

PARTICIPANTS:

All
patients with arch anomalies who underwent surgery for acute Stanford
type-A aortic dissection during the study period (n = 43).

INTERVENTIONS:

Surgical
management, anesthetic monitoring, and perfusion strategy were analyzed
in a retrospective fashion. No new interventions were undertaken as
part of this study.

MEASUREMENTS AND MAIN RESULTS:

Management
differed most in patients with an aberrant right subclavian artery (n =
5), because the institutional standard of right axillary artery
cannulation with left upper extremity arterial pressure monitoring was
not possible. In patients with one of two “bovine” arch patterns (n =
32), management differed in the conduct of selective antegrade cerebral
perfusion, which could include clamping above or below the takeoff of
the left common carotid artery (and, therefore, produced unilateral or
bilateral antegrade cerebral perfusion). All patients with a connective
tissue disorder exhibited a bovine arch pattern. Management of patients
with a right arch (n = 3) reflected the opposite of management for
normal anatomy (for patients with traditional mirror-image branching) or
opposite that of the aberrant right subclavian group (for patients who
had a corresponding aberrant left subclavian artery).

CONCLUSIONS:

Rational
management reflected the anatomic variations observed. These results
support the importance of interdisciplinary planning, especially in an
emergency, to optimize outcome.