Recurrent Stroke After Acute Type A Aortic Dissection Repair: Endovascular Revascularization of the Proximal Left Common Carotid Artery Using an Unusual Setup

Aortic dissection is an uncommon, life-threatening, treatable emergency that typically presents with tearing chest and back pain. Using the Stanford Classification, aortic dissections can be divided into Type A, involving the ascending aorta, and Type B, involving the aorta distal to the origin of the left subclavian artery. Type A dissections may cause ischemic stroke in up to 5–10% of patients through the extension of the dissection into the common carotid arteries (CCA) or through thromboembolism or cerebral hypoperfusion. Endovascular stroke therapy can pose unusual challenges in patients with concomitant aortic dissection and acute ischemic stroke. A 47-year-old woman presented with a history of poorly controlled hypertension, hypothyroidism, sinus bradycardia, and acute Type A aortic dissection. She had undergone ascending aorta replacement during the acute phase that had complicated with a perioperative left hemispheric stroke of mixed embolic and hemodynamic etiology. She had recovered ad integrum from this event. Her father had suffered from aortic aneurysm. One month after surgical repair, she was readmitted for acute right hemiparesis and fluctuating motor dysphasia (National Institutes of Health Stroke Scale [NIHSS] score 8). Symptoms had started an hour before admission. Blood pressure in her right and left arms was 100/60 and 130/80 mmHg, respectively. Cranial CT and MRI showed multiple infarcts in watershed distribution on the left hemisphere. CT angiography (CTA) of the chest showed severe ostial narrowing of the left CCA secondary to aortic arch dissection, and CT perfusion (CTP) images showed left hemispheric hypoperfusion. Stenting was performed to treat acutely symptomatic ostial stenosis of the left CCA. Through the right femoral artery, a 4F diagnostic catheter was navigated through the descending aorta with the aid of a regular guidewire. Careful guidewire manipulation allowed catheterization of the true lumen of the aorta and placement of the diagnostic catheter at the proximal left CCA. The diagnostic catheter was exchanged for an 8F guiding catheter, and the exchange guidewire was left at the left external carotid artery (ECA). The guiding catheter was left at the aortic arch immediately distal to the left CCA ostium. Proximal CCA stenting using two telescoped Wallstents measuring 9/30 mm and 9/40 mm allowed revascularization of the CCA trunk. The proximal end of the second stent was intentionally left protruding into the lumen of the aortic arch to mechanically distract the dissecting intimal flap from the CCA ostium, ensuring patency of the lumen and, consequently, antegrade flow. The patient tolerated the intervention without complications and was extubated after manual removal of the introducer sheath. Neurological examination performed on postoperative day 1 showed improvement in the left hemiparesis and resolution of dysphasia (Glasgow Coma Score [GCS] 15 and NIHSS score 2). On follow-up CTA, the implanted stents were patent. The patient was managed with dual antiplatelet, antihypertensive, and diuretic medications. This chapter deals with Type A acute aortic dissection, its surgical repair, and ischemic stroke that resulted in our patient. A left CCA stent-assisted revascularization procedure with an excellent clinical evolution is described.