Management and outcomes of carotid artery extension of aortic dissections

Adriana Laser, Charles B. Drucker, Donald G. Harris, Tanya Flohr, Shahab Toursavadkohi, Rajabrata Sarkar, Bradley Taylor, Robert S. Crawford

Research output: Contribution to journalArticle

Abstract

Background Aortic dissection (AD) is the most common aortic catastrophe. Carotid artery dissection due to extension of AD (CAEAD) is one severe complication of this condition. Despite years of refinement in the techniques for repair of AD, the optimal management strategy for CAEAD remains yet to be described. We hypothesized that CAEAD eventually resolves on antiplatelet therapy with a low but not insignificant risk of cerebrovascular accident (CVA). Methods This was a single-institution retrospective review of patients admitted with nontraumatic coincident aortic and carotid dissection between 2001 and 2013. Results CAEAD was present in 38 patients (24 men [53%]). The median age was 59.5 years (range, 25-85 years). A Stanford type A AD was diagnosed in 36 patients (95%). CVA or transient ischemic attack was identified in 11 patients (29%). Eight were potentially attributable to the carotid lesion. Two of these eight strokes resulted in death. Of the 11 CVAs and transient ischemic attacks, 8 were evident at presentation, 2 were diagnosed postoperatively during hospitalization, and 1 was diagnosed during early follow-up. Only one of these three postadmission strokes was attributable to the carotid lesion. Nonoperative management of aortic and carotid dissections was pursued in 9 patients (24%), 26 (68%) underwent open repair, and 4 (11%) had endovascular management of AD (2 thoracic endovascular aortic repair, 2 endovascular fenestrations), including 1 patient with a staged hybrid procedure (frozen elephant trunk). There were eight inpatient deaths (21%) and nine deaths in the follow-up period. Of the 30 patients who survived to discharge, 24 (80%) were managed with antiplatelet therapy. At a median follow-up of 14.5 months in 22 patients with follow-up computed tomography scans available, a minority of lesions had resolved, and only one CVA was reported. Conclusions This study found that CAEAD was associated almost exclusively with type A AD, was typically unilateral, most often on the left, and usually persisted at follow-up. Many CAEAD patients presented with CVA and experienced significant early mortality. Notably, not all CVA events were attributable to the CAEAD. CVAs were not common after admission, and there appeared to be a low risk of new or subsequent stroke during follow-up with routine antiplatelet and antihypertensive therapy.

Original languageEnglish (US)
Pages (from-to)445-453
Number of pages9
JournalJournal of Vascular Surgery
Volume66
Issue number2
DOIs
StatePublished - Aug 1 2017

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Carotid Arteries
Dissection
Stroke
Transient Ischemic Attack
Antihypertensive Agents
Inpatients
Hospitalization
Thorax
Therapeutics
Tomography
Mortality

All Science Journal Classification (ASJC) codes

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

Laser, A., Drucker, C. B., Harris, D. G., Flohr, T., Toursavadkohi, S., Sarkar, R., ... Crawford, R. S. (2017). Management and outcomes of carotid artery extension of aortic dissections. Journal of Vascular Surgery, 66(2), 445-453. https://doi.org/10.1016/j.jvs.2016.12.137
Laser, Adriana ; Drucker, Charles B. ; Harris, Donald G. ; Flohr, Tanya ; Toursavadkohi, Shahab ; Sarkar, Rajabrata ; Taylor, Bradley ; Crawford, Robert S. / Management and outcomes of carotid artery extension of aortic dissections. In: Journal of Vascular Surgery. 2017 ; Vol. 66, No. 2. pp. 445-453.
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title = "Management and outcomes of carotid artery extension of aortic dissections",
abstract = "Background Aortic dissection (AD) is the most common aortic catastrophe. Carotid artery dissection due to extension of AD (CAEAD) is one severe complication of this condition. Despite years of refinement in the techniques for repair of AD, the optimal management strategy for CAEAD remains yet to be described. We hypothesized that CAEAD eventually resolves on antiplatelet therapy with a low but not insignificant risk of cerebrovascular accident (CVA). Methods This was a single-institution retrospective review of patients admitted with nontraumatic coincident aortic and carotid dissection between 2001 and 2013. Results CAEAD was present in 38 patients (24 men [53{\%}]). The median age was 59.5 years (range, 25-85 years). A Stanford type A AD was diagnosed in 36 patients (95{\%}). CVA or transient ischemic attack was identified in 11 patients (29{\%}). Eight were potentially attributable to the carotid lesion. Two of these eight strokes resulted in death. Of the 11 CVAs and transient ischemic attacks, 8 were evident at presentation, 2 were diagnosed postoperatively during hospitalization, and 1 was diagnosed during early follow-up. Only one of these three postadmission strokes was attributable to the carotid lesion. Nonoperative management of aortic and carotid dissections was pursued in 9 patients (24{\%}), 26 (68{\%}) underwent open repair, and 4 (11{\%}) had endovascular management of AD (2 thoracic endovascular aortic repair, 2 endovascular fenestrations), including 1 patient with a staged hybrid procedure (frozen elephant trunk). There were eight inpatient deaths (21{\%}) and nine deaths in the follow-up period. Of the 30 patients who survived to discharge, 24 (80{\%}) were managed with antiplatelet therapy. At a median follow-up of 14.5 months in 22 patients with follow-up computed tomography scans available, a minority of lesions had resolved, and only one CVA was reported. Conclusions This study found that CAEAD was associated almost exclusively with type A AD, was typically unilateral, most often on the left, and usually persisted at follow-up. Many CAEAD patients presented with CVA and experienced significant early mortality. Notably, not all CVA events were attributable to the CAEAD. CVAs were not common after admission, and there appeared to be a low risk of new or subsequent stroke during follow-up with routine antiplatelet and antihypertensive therapy.",
author = "Adriana Laser and Drucker, {Charles B.} and Harris, {Donald G.} and Tanya Flohr and Shahab Toursavadkohi and Rajabrata Sarkar and Bradley Taylor and Crawford, {Robert S.}",
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Laser, A, Drucker, CB, Harris, DG, Flohr, T, Toursavadkohi, S, Sarkar, R, Taylor, B & Crawford, RS 2017, 'Management and outcomes of carotid artery extension of aortic dissections', Journal of Vascular Surgery, vol. 66, no. 2, pp. 445-453. https://doi.org/10.1016/j.jvs.2016.12.137

Management and outcomes of carotid artery extension of aortic dissections. / Laser, Adriana; Drucker, Charles B.; Harris, Donald G.; Flohr, Tanya; Toursavadkohi, Shahab; Sarkar, Rajabrata; Taylor, Bradley; Crawford, Robert S.

In: Journal of Vascular Surgery, Vol. 66, No. 2, 01.08.2017, p. 445-453.

Research output: Contribution to journalArticle

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T1 - Management and outcomes of carotid artery extension of aortic dissections

AU - Laser, Adriana

AU - Drucker, Charles B.

AU - Harris, Donald G.

AU - Flohr, Tanya

AU - Toursavadkohi, Shahab

AU - Sarkar, Rajabrata

AU - Taylor, Bradley

AU - Crawford, Robert S.

PY - 2017/8/1

Y1 - 2017/8/1

N2 - Background Aortic dissection (AD) is the most common aortic catastrophe. Carotid artery dissection due to extension of AD (CAEAD) is one severe complication of this condition. Despite years of refinement in the techniques for repair of AD, the optimal management strategy for CAEAD remains yet to be described. We hypothesized that CAEAD eventually resolves on antiplatelet therapy with a low but not insignificant risk of cerebrovascular accident (CVA). Methods This was a single-institution retrospective review of patients admitted with nontraumatic coincident aortic and carotid dissection between 2001 and 2013. Results CAEAD was present in 38 patients (24 men [53%]). The median age was 59.5 years (range, 25-85 years). A Stanford type A AD was diagnosed in 36 patients (95%). CVA or transient ischemic attack was identified in 11 patients (29%). Eight were potentially attributable to the carotid lesion. Two of these eight strokes resulted in death. Of the 11 CVAs and transient ischemic attacks, 8 were evident at presentation, 2 were diagnosed postoperatively during hospitalization, and 1 was diagnosed during early follow-up. Only one of these three postadmission strokes was attributable to the carotid lesion. Nonoperative management of aortic and carotid dissections was pursued in 9 patients (24%), 26 (68%) underwent open repair, and 4 (11%) had endovascular management of AD (2 thoracic endovascular aortic repair, 2 endovascular fenestrations), including 1 patient with a staged hybrid procedure (frozen elephant trunk). There were eight inpatient deaths (21%) and nine deaths in the follow-up period. Of the 30 patients who survived to discharge, 24 (80%) were managed with antiplatelet therapy. At a median follow-up of 14.5 months in 22 patients with follow-up computed tomography scans available, a minority of lesions had resolved, and only one CVA was reported. Conclusions This study found that CAEAD was associated almost exclusively with type A AD, was typically unilateral, most often on the left, and usually persisted at follow-up. Many CAEAD patients presented with CVA and experienced significant early mortality. Notably, not all CVA events were attributable to the CAEAD. CVAs were not common after admission, and there appeared to be a low risk of new or subsequent stroke during follow-up with routine antiplatelet and antihypertensive therapy.

AB - Background Aortic dissection (AD) is the most common aortic catastrophe. Carotid artery dissection due to extension of AD (CAEAD) is one severe complication of this condition. Despite years of refinement in the techniques for repair of AD, the optimal management strategy for CAEAD remains yet to be described. We hypothesized that CAEAD eventually resolves on antiplatelet therapy with a low but not insignificant risk of cerebrovascular accident (CVA). Methods This was a single-institution retrospective review of patients admitted with nontraumatic coincident aortic and carotid dissection between 2001 and 2013. Results CAEAD was present in 38 patients (24 men [53%]). The median age was 59.5 years (range, 25-85 years). A Stanford type A AD was diagnosed in 36 patients (95%). CVA or transient ischemic attack was identified in 11 patients (29%). Eight were potentially attributable to the carotid lesion. Two of these eight strokes resulted in death. Of the 11 CVAs and transient ischemic attacks, 8 were evident at presentation, 2 were diagnosed postoperatively during hospitalization, and 1 was diagnosed during early follow-up. Only one of these three postadmission strokes was attributable to the carotid lesion. Nonoperative management of aortic and carotid dissections was pursued in 9 patients (24%), 26 (68%) underwent open repair, and 4 (11%) had endovascular management of AD (2 thoracic endovascular aortic repair, 2 endovascular fenestrations), including 1 patient with a staged hybrid procedure (frozen elephant trunk). There were eight inpatient deaths (21%) and nine deaths in the follow-up period. Of the 30 patients who survived to discharge, 24 (80%) were managed with antiplatelet therapy. At a median follow-up of 14.5 months in 22 patients with follow-up computed tomography scans available, a minority of lesions had resolved, and only one CVA was reported. Conclusions This study found that CAEAD was associated almost exclusively with type A AD, was typically unilateral, most often on the left, and usually persisted at follow-up. Many CAEAD patients presented with CVA and experienced significant early mortality. Notably, not all CVA events were attributable to the CAEAD. CVAs were not common after admission, and there appeared to be a low risk of new or subsequent stroke during follow-up with routine antiplatelet and antihypertensive therapy.

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