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Outcomes of Medically Managed Carotid Artery Dissection After Repair of Acute Aortic Dissection
Kristofer M Charlton-Ouw1, Ali Sawal2, Samuel S Leake1, Harleen K Sandhu1, Charles C Miller, III3, Sheila M Coogan1, Ali Azizzadeh1, Anthony L Estrera1, Hazim J Safi1
1University of Texas Medical School, Houston, TX;2William Carey University College of Osteopathic Medicine, Hattiesburg, MS;3Texas Tech University Paul L. Foster School of Medicine, El Paso, TX
INTRODUCTION: 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) after open ascending aortic repair, the natural history and risk of stroke is unclear. We examine our experience with CCAD after acute aortic dissection repair to determine risk of stroke and need for carotid revascularization.
METHODS: We queried our cases of type A aortic dissection over a ten-year period from January 2002 to December 2011. Imaging was reviewed to determine presence of CCAD, degree of true-lumen stenosis and false-lumen patency. Analysis was performed to determine risk of stroke and survival on initial presentation and during follow-up. Survival between groups was compared using Log-Rank statistics.
RESULTS: We repaired 288 cases of type A aortic dissection during the study period. Adequate carotid imaging was available in 179 patients and comprised the study group. We identified 44 cases with (group A, 24.6%) and 135 cases without CCAD (group B, 75.4%). History of previous stroke was not a risk factor in either group (11.3% vs 11.1%, p=0.96). Bilateral CCAD occurred in 15 cases (34.1%). Stroke on initial presentation of aortic dissection was more common in group A (15.9%) than in group B (7.4%) (OR 2.4, 95%CI 0.84-6.65, p=0.096). Degree of stenosis or false lumen thrombosis did not appear to affect rate of stroke on presentation. The degree of postoperative true lumen stenosis ranged from 0% (resolution) to 90%. The functional degree of stenosis was difficult to quantify in cases of persistent false lumen patency. No patient with CCAD had postoperative stroke or required carotid revascularization in hospital or on follow-up. The 5-year stroke-free survival in the CCAD group and the non-CCAD group were 73.0% and 78.5% (p=0.71), respectively.
CONCLUSIONS: CCAD after open repair of acute type A aortic dissection appears to have a low risk of postoperative neurologic events. Based on the currently available data, there is little evidence to suggest that CCAD requires repair in the absence of symptoms regardless of degree of stenosis or false lumen patency. Additional longitudinal studies are needed. 
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