J Extra Corpor Technol 2025, 57, 153--159 Ó The Author( s), published by EDP Sciences, 2025 https:// doi. org / 10.1051 / ject / 2025011
Available online at: ject. edpsciences. org
CASE REPORT
An effective case of pulsatile flow for cerebral malperfusion of stanford type A aortic dissection
Tomohisa Takeichi( CE) 1,*, Yoshihisa Morimoto( MD) 2, Akitoshi Yamada( MD) 2, Takanori Tanaka( CE) 1, Kunihiro Fujiwara( CE) 1, Masanobu Sato( MD) 2, Ryo Toma( MD) 2, Kiyoto Mitsui( CE) 1, Takumi Sugita( CE) 1, and Kunio Gan( MD) 2 1 Department of Clinical Engineering, Kitaharima Medical Center, 926-250, Ichiba-cho, Ono-shi, Hyogo, 675-1392, Japan 2 Department of Cardiovascular Surgery, Kitaharima Medical Center, 926-250, Ichiba-cho, Ono-shi, Hyogo, 675-1392, Japan
Received 2 September 2024, Accepted 31 March 2025
Abstract – The surgical management of preoperative malperfusion poses considerable challenges, particularly in cases of acute type A aortic dissection( TAAD). Herein, we describe the case of a 78-year-old female patient presenting with TAAD complicated by malperfusion of the left lower extremity and an entry tear localized to the ascending aorta. During the initiation of cardiopulmonary bypass( CPB), a pronounced bilateral discrepancy in radial mean arterial blood pressure( mABP) was identified, alongside a significant reduction in cerebral tissue oxygenation index( TOI) and the oxyhemoglobin change rate( DHbO 2). To mitigate the malperfusion, pulsatile flow( PF) was utilized during CPB. This report elucidates the meticulous application of PF during CPB in the management of this complex malperfusion scenario, culminating in a favorable postoperative outcome.
Key words: Malperfusion, Pulsatile flow, Aortic dissection, Near-infrared spectroscopic oximetry( NIRO). Introduction
Acute type A aortic dissection( TAAD) outcomes are profoundly influenced by complex malperfusion syndromes, which substantially elevate mortality rates [ 1 ]. Lower-limb malperfusion is reported in approximately 20--30 % of TAAD cases [ 2--6 ]. Although femoral artery cannulation is commonly utilized in the management of TAAD, it is associated with several inherent limitations. Alternatively, strategies incorporating axillary and femoral artery cannulation or employing ascending aorta( Asc Ao) cannulation have demonstrated improved postoperative clinical outcomes [ 7--9 ].
In cases complicated by malperfusion, the selection of an appropriate perfusion strategy is paramount. In the presented case, a decision was made to utilize a combination of right femoral artery( FA) and Asc Ao cannulation. However, due to severe narrowing of the true lumen and pronounced mobility of the intimal flap, aortic cannulation was technically challenging. As a result, cardiopulmonary bypass( CPB) was initiated via right FA cannulation. Following the establishment of CPB, a significant bilateral discrepancy in radial mean arterial blood pressure( mABP) was observed. Concurrently, cerebra tissue oxygenation index( TOI) and DHbO 2 demonstrated
* Corresponding author: tommo. tommo @ outlook. jp notable declines. To mitigate malperfusion, the perfusion mode was transitioned from non-pulsatile flow( NPF) to pulsatile flow( PF).
This case report was approved by the Institutional Review Board at Kitaharima medical center( IRB 06-34) with the waiver of informed consent.
Case report
The patient, a 78-year-old woman( height: 155.3 cm; weight: 49.7 kg), was transported to our hospital following the acute onset of back pain and impaired mobility in the left lower limb. Her medical history was significant for annuloaortic ectasia, previously monitored at our institution. Upon examination in the emergency department, the patient was alert and oriented. Contrast-enhanced computed tomography( CT) revealed a type A aortic dissection( TAAD) with malperfusion of the left lower limb and an entry tear in the ascending aorta( Fig. 1a). The left common carotid artery( LCCA) and left subclavian artery( LSCA) were unremarkable( Fig. 1b). The true lumen was compressed by the false lumen, extending from the brachiocephalic artery( BCA) to the right common carotid artery( RCCA) including the right axillary artery( Figs. 1a--1c). Emergency surgery, including a Bentall procedure and hemiarch replacement, was indicated.
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