Is coma an absolute contraindication for emergency central aortic operation?

Abstract

Clinical Summary The patient was a 79-year-old man. Left hemiplegia and loss of consciousness developed suddenly, and he was transferred to our emergency center under suspicion of brain infarction. On admission, his Glasgow coma scale was E1 V1 M1. Although brain computed tomography (CT) revealed no abnormal finding except for atrophy, body enhanced CT confirmed acute Stanford type A aortic dissection complicated with brain malperfusion caused by extension of the dissected flap to the innominate artery. Four hours after development of coma, an emergency operation was performed. Extracorporeal circulation was established by means of infusion into the left axillary artery and drainage from the right atrium. At a bladder temperature of 28°C, the aorta was clamped between the innominate and left carotid arteries. After incision of the ascending aorta, chemical arrest was induced by means of direct infusion of cardioplegic solution into the bilateral coronary artery, and selective innominate artery perfusion was performed by means of direct cannulation into the true lumen from the orifice with a balloon cannula. Graft replacement of the aorta was performed from above the sinotubular junction to the aortic arch proximal to the left carotid artery. The entire length of the dissected portion of the innominate artery was resected and reconstructed with a branched graft from the aortic graft. Fourteen hours after the operation, the patient awakened clearly with mild muscle weakness of the left upper limb, and the endotracheal tube was removed. Two days after the operation, he was able to walk. Fifteen days after the operation, he was discharged from our hospital. The brain CT scan during the follow-up period at another hospital revealed infarction at the right putamen. Brain magnetic resonance imaging (Figure 1) 25 days after the operation revealed hemorrhage at the infarction site; however, no significant paralysis developed. Three months after the operation, the patient returned to his life as a farmer.