Surgical Management of Acute Aortic Dissection Complicated by Stroke

Fann, James I. MD
Sarris, George E. MD
Miller, D. Craig MD
Mitchell, R. Scott MD
Oyer, Philip E. MD, PhD
Stinson, Edward B. MD
Shumway, Norman E. MD, PhD

From the Department of Cardiovascular Surgery, Stanford University School of Medicine, Stanford, California.

Address for correspondence: D.C. Miller, MD, Department of Cardiovascular Surgery, Cardiovascular Research Center, Stanford University Medical Center, Stanford, CA 94305–5247.

J.I.F. and G.E.S. are Carl and Leah McConnell Cardiovascular Surgical Research Fellows. G.E.S. was also supported by the Alexander Onassis Public Benefit Foundation, Vaduz, Liechtenstein.

Circulation 80(3):p I257-I263, September 1989.

Although patients with acute type A aortic dissection are best managed by emergency surgical intervention, preoperative stroke is known to be an independent predictor of late mortality and is considered by some to be a contraindication to operation because of the risk of precipitating hemorrhagic cerebral infarction and poor long-term outcome. In a series of 272 consecutive, unselected patients with aortic dissection undergoing surgical treatment during a 25-year span (1963–1987), 128 (47±3% [±70% confidence level {CL}]) had an acute type A dissection. A total of seven patients with acute type A dissection (2.6±1% of all patients, 5.5 ±2% of the acute type A cohort) developed a new stroke preoperatively. Thirteen (4.8±1%) patients had a diminished or absent carotid pulse, only four (31±13%) of whom sustained a stroke. One patient died in the immediate postoperative period due to severe brain injury, yielding an operative mortality rate of 14±14%. Two patients had persistent neurological deficits and died within 4 months of operation; the actuarial survival estimate at 1 year was 57±19% (mean±SEM). One patient recovered function of one upper extremity (preoperative left hemiparesis compounded by paraplegia) but died 6 years later. The remaining three long-term survivors (43±19%) had major resolution of their neurological deficits and are clinically well 2–8 years postoperatively. Stroke was a prominent element of the clinical presentation in a small minority of patients with acute type A dissection and portends less favorable long-term survival; however, stroke should constitute only a relative contraindication to operation at most, as full neurological recovery and satisfactory long-term outcomes are possible.