The Western Thoracic Surgical Association

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Predictors of Acute Stroke after Type A Aortic Dissection Repair: An Analysis of the STS Adult Cardiac Surgery Database
Mehrdad Ghoreishi1, Thoralf M Sundt2, Duke E Cameron2, Eric E Roselli3, Bartley P Griffith1, Chetan Pasrija1, Robert Habib4, James S Gammie1, Lars G Svensson3, Joseph Bavaria5, Bradley S Taylor1
1University of Maryland School of Medicine, Baltimore, MD;2Massachusetts General Hospital, Boston, MA;3Heart and Vascular Institute Cleveland Clinic, Cleveland, OH;4STS Research Center, Chicago, IL;5Hospital of the University of Pennsylvania, Philadelphia, PA

OBJECTIVES: Despite significant improvement in surgical techniques, the rate of stroke after acute type A aortic dissection repair remains high (10%-30%). We used the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) to examine the incidence and predictors of acute stroke following type A repair.
METHODS: All acute type A aortic dissection repairs performed from July 2011 to July 2017 were identified from the STS ACDS. Patients who presented with acute stroke (N=324) and those with a history of chronic stroke (N=439) were excluded. The impact of cannulation strategy (axillary, femoral, direct), circulation management [deep hypothermia (<22), moderate (22-25) or mild (>25)], cerebral protection techniques (antegrade, retrograde, both, hypothermia alone), and institutional annual volume (low volume center if < 10 cases/year vs. high volume center if > 10 cases/year) on postoperative stroke was investigated. Stepwise variable selection was used to create a risk model for adjustment of multivariable analysis.
RESULTS: Acute type A repair was performed on 8161 patients at 759 centers. Operative mortality was 17% (N=1395). The incidence of postoperative stroke was 13% (N=1061). The most common arterial cannulation for cardiopulmonary bypass were axillary 35% (N=2798), femoral 32% (N=2523) and direct aortic 27% (N=2131). Deep hypothermia was used in 62% (N=4921), moderate hypothermia in 18% (N=1395) and mild hypothermia in 20% (N=1576). Cerebral perfusion strategies were antegrade in 65% (N=3653), retrograde in 31% (N=1748), and both in 4% (N=242). Circulatory arrest without cerebral perfusion occurred in 29% (N=2294) and was not associated with greater risk of postoperative stroke (P = 0.09) (Table). 17 centers performed > 10 cases per year and 125 centers performed only one case during the study period. Thoracic endovascular aortic repair was performed in 4% (N=341) and was not associated with increased risk of stroke (P = 0.3). Risk adjustment showed femoral cannulation (OR = 1.825, 95% CI 1.179 - 2.823, P = 0.006) and direct aortic cannulation (OR = 1.696, 95% CI 1.078 - 2.666, P = 0.02) increased the risk of postoperative stroke compared with axillary cannulation. Other adjusted risks for postoperative stroke included total arch replacement (OR = 1.615, 95% CI 1.066 - 2.448, P = 0.0237), ejection fraction (OR = 1.023, 95% CI 1.003 - 1.043, P = 0.0259), and baseline Cr (OR = 1.211, 95% CI 1.083 - 1.354, P = 0.0008). Hospital volume had no statistically significant effect on postoperative stroke [13% (919 / 7059) among low volume centers vs. 13% (142 / 1102) among high volume centers P = 0.9).
CONCLUSIONS: Stroke is a common complication of acute type A repair. Axillary artery cannulation is associated with the lowest stroke rate in acute type A repair. Hypothermic circulatory arrest without cerebral perfusion does not increase the risk of postoperative stroke.


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