Management of common carotid artery dissection due to extension from acute type A (DeBakey I) aortic dissection

Abstract

Acute type A aortic dissection can extend into arch vessels, including the common carotid arteries. Although several reports describe concomitant endovascular repair of common carotid artery dissection (CCAD) during open ascending aortic repair, the criteria for repair, natural history, and risk of stroke are unclear. We examine the literature and our experience with nonoperative management of CCAD after acute aortic dissection repair to determine the risk of stroke and the need for carotid revascularization. We queried our cases of type A aortic dissection over a 10-year period from January 2002 to December 2011. Imaging was reviewed to determine the presence of CCAD and degree of true-lumen stenosis. Analysis was performed to determine risk of stroke and survival on initial presentation and during follow-up. Survival functions between excluded groups and those with and without CCAD were compared using log-rank statistics. We repaired 288 cases of acute type A aortic dissection during the study period. Adequate carotid imaging was available in 179 patients and comprised the study group. We identified 43 cases with CCAD (group A, 24.0%) and 136 cases without it (group B, 76.0%). History of previous stroke was not a risk factor for new stroke in either group (P = .517). Bilateral CCAD occurred in 16 cases (37.2%). Stroke on initial presentation was more common in group A (18.6%) than in group B (8.1%; odds ratio, 2.6; 95% confidence interval, 0.97-6.95; P = .051). Degree of stenosis or false-lumen thrombosis did not affect rate of stroke on presentation. The degree of postoperative true-lumen stenosis ranged from 0% (resolution) to 90%. No patient with CCAD had stroke or required carotid revascularization after discharge on follow-up. The 5-year, stroke-free survival rates in groups A and B were 69.7% and 73.6% (P = .820), respectively. CCAD, due to extension from aortic arch dissection, has a low risk of subsequent stroke after the initial event. Based on current data, there is little evidence to suggest that aortic origin CCAD requires repair in the absence of recurrent symptoms, regardless of the degree of stenosis or false-lumen patency. Recommended optimal medical therapy includes either aspirin or anticoagulation for 6 months after initial presentation. Additional longitudinal studies are needed.