Postoperative Stroke Severity in Acute Type A Aortic Dissection: Outcomes of a Three-Center Cohort

Background: Strokes are among the most severe complications for survivors of acute type A aortic dissection (aTAAD), and are, in essence, heterogeneous in presentation. The Modified Rankin Scale (mRS), with scores from 0 (no symptoms) to 6 (death), evaluates disability. Despite its established utility, current literature often lacks stratification of stroke severity. We present the outcomes of patients following surgery for aTAAD using the mRS in a retrospective three-center cohort.

Methods: A registry of 2,255 patients who had surgery for aTAAD between 2007 and 2022 was created. 375 patients with postoperative stroke were stratified into 2 groups: those with severe disability (mRS > 3, requiring assistance) and those with non to moderate disability (mRS ≤ 3, no assistance). An mRS of 6 represented the 30-day mortality.

Results: Patients were classified into mRS ≤ 3 group (111 patients) and mRS > 3 group (264 patients). Patients in the latter group were older (65.2 ± 11.9 versus 59.7 ± 12.7 years, p < 0.001) with higher BMI (38.7 ± 6.6 versus 27.2 ± 5.1 kg/m², p = 0.033); incidences of cerebral and peripheral malperfusion were more frequent at 44.4% versus 32.4% (p = 0.045) and 31% versus 11% (p = 0.011). There was a higher incidence of right common carotid artery dissection in the mRS > 3 group (71.9% versus 28%, p = 0.005). Logistic regression confirmed this with ORs of 2.44 (95% CI: 1.33–4.51) in univariate and 2.08 (95% CI: 1.09–4.01) in multivariate analyses. No variance was observed in arch procedures (p = 0.59). CBP time was longer in the mRS > 3 group 206 (158, 267) versus 185 (145, 245) min (p = 0.026). Axillary cannulation was higher in mRS ≤ 3 73% versus 56.3% (p = 0.007). 30-day mortality was 81(21.6%). Re-sternotomy for bleeding (p = 0.024), dialysis (p < 0.001), and tracheostomy (p < 0.001) occurred more in the mRS > 3 group. New strokes in patients without preoperative neurological impairment were more frequent in the mRS > 3 group, without reaching significance (p = 0.089). Survival at 5 years was lower in the 30-day survivors in the mRS > 3 group: 70.9% (CI95%: 63, 80) vs. 86.1% (CI95%: 78.7, 94) (log rank p < 0.001). Multivariable Cox regression at 5 years confirmed that an mRS > 3 was a stronger predictor of survival than age at surgery HR: 2.40 (95% CI: 1.21, 4.77) and HR: 1.02 (95% CI:0.99, 1.05).

Conclusion: The mRS at discharge predicts midterm survival. Prolonged CBP time and involvement of the right common carotid artery were associated with worse neurological outcomes whereas axillary cannulation was protective.

Publikationsverlauf

Artikel online veröffentlicht:
11. Februar 2025