Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation?

Is axillary artery cannulation necessary in type II hybrid aortic arch repair for acute type A aortic dissection?

INTRODUCTION

Axillary artery cannulation (AAC) has been widely employed in total arch replacement surgeries using the frozen elephant trunk (FET) technique for acute type A aortic dissection (ATAAD), showing better clinical results than femoral artery cannulation (FAC). Nevertheless, in type II hybrid arch repair (HAR), FAC is crucial for lower body perfusion. Hence, it is unclear whether AAC remains necessary or if AAC represents a more advantageous method for initiating cardiopulmonary bypass.

METHODS

We conducted a study involving patients diagnosed with ATAAD who underwent type II HAR from August 2021 to December 2022. Demographic baseline and intraoperative data were collected, and the postoperative outcomes of patients receiving FAC only were compared with those receiving AAC.

RESULTS

There were no significant differences in baseline demographics between patients who underwent FAC alone (n = 46) and those who underwent AAC (n = 39). Patients who underwent AAC showed a lower incidence of transient neurological dysfunction (TND) post-surgery compared to those who underwent FAC (12.8% vs 32.6%, p = .032). There were no significant differences between the groups in terms of postoperative mortality within 30 days, permanent neurological dysfunction (PND), length of stay in the intensive care unit (ICU) and postoperative ward, duration of mechanical ventilation, and other complications.

CONCLUSIONS

Axillary artery cannulation may decrease the incidence of postoperative transient neurological dysfunction (TND) in type II HAR for ATAAD. Nonetheless, studies with larger sample sizes are necessary.

A comparison of single and double arterial cannulation for cardiopulmonary bypass for acute type A aortic surgery: A single center, retrospective observational study

Background: Acute type A aortic dissection (ATAAD) is a cardiovascular emergency and has high mortality and morbidity. We retrospectively compared the effects on outcomes of single arterial cannulation via axillary artery (AAC) with double arterial cannulation via axillary and femoral artery (DAC) in patients who underwent cardiopulmonary bypass (CPB) for ATAAD.Methods: Between January 2017 and May 2021, four hundred 29 patients who underwent aortic arch repair with circulatory arrest for ATAAD were divided into AAC group (n = 283) and DAC group (n = 146). The propensity score-matched (PSM) analysis were performed to compare the characteristics and outcomes of the groups.Results: After PSM (n = 137 in each), the DAC group had a longer duration of CPB (229 vs 244, p = 0.011), aortic cross-clamp time (121 vs 149, p < 0.001), durations of Intensive Care Unit (ICU) stay (7 vs 8, p = 0.014) and hospital stay (19 vs 25, p < 0.001) compared with AAC group. The incidences of dialysis (21% vs. 31%, p = 0.073), postoperative stroke (9% vs 15%, p = 0.143), ECMO support (2% vs 7%, p = 0.077), in-hospital mortality (7% vs 14%, p = 0.071) and follow-up mortality (10% vs 19%, p = 0.059) showed no significant difference between two groups. Multivariate logistic regression analysis showed postoperative ECMO (OR: 16.69, 95% CI: 1.78-156.29; p = 0.014) or stroke (OR: 11.34, 95% CI: 2.64-48.72; p < 0.001) were associated with in-hospital mortality. Univariate Cox regression results showed stroke history (OR: 4.61, 95% CI: 1.90-11.16; p = 0.001), aortic valvuloplasty (OR: 0.21, 95% CI: 0.07-0.59; p = 0.003), postoperative ALT day1 (OR: 1.00, 95% CI: 1.00-1.00; p = 0.008), ECMO (OR: 16.30, 95% CI: 4.78-55.61; p < 0.001), tracheotomy (OR: 3.78, 95% CI: 1.08-13.20; p = 0.037), postoperative stroke (OR: 4.61, 95% CI: 1.90-11.16; p < 0.001) and re-exploration for bleeding (OR: 3.52, 95% CI: 1.01-12.27; p = 0.048) were associated to follow-up mortality.Conclusions: For surgical treatment of ATAAD with CPB when compared to double axillary and femoral artery, single axillary cannulation was associated with shorter durations of CPB and ACC as well as ICU and hospital stays but no with significant difference in mortality.

Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Femoral artery cannulation increases the risk of postoperative stroke in patients with acute DeBakey I aortic dissection

BACKGROUND

The selection of different arterial cannulation site influences the incidence of postoperative stroke in patients with DeBakey I acute aortic dissection. The study aimed to explore the optimal arterial cannulation for these patients.

METHODS

From January 2009 to 2019, a total of 1514 patients with DeBakey I acute aortic dissection underwent frozen elephant trunk and total arch replacement at a tertiary center. They were divided into 2 groups: the axillary artery only cannulation group (n = 1075) and the femoral artery cannulation group (n = 439). After balancing the differences of baseline condition by propensity score matching, the prognosis was compared.

RESULTS

The incidence of stroke and acute brain infarction in the femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 11.7% vs 7.0%, P = .03; acute brain infarction, 6.0% vs 2.7%, P < .01). The femoral artery cannulation group was further divided into 2 groups: femoral artery only cannulation group (n = 106) and axillary combined with femoral artery cannulation group (n = 333). The comparison was performed between the axillary combined with femoral artery cannulation group and the axillary artery only cannulation group. After propensity score matching, the incidence of stroke and acute brain infarction in the axillary combined with femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 13.5% vs 7.2%, P < .01; acute brain infarction, 6.9% vs 2.5%, P < .01).

CONCLUSIONS

Axillary artery only cannulation is recommended as the optimal arterial cannulation strategy for most patients with DeBakey I acute aortic dissection. For those patients who are not suitable for axillary artery only cannulation, axillary combined with femoral artery cannulation is not recommended.

Central aortic versus axillary artery cannulation for aortic arch surgery

Objective

Central aortic cannulation for aortic arch surgery has become more popular over the last decade; however, evidence comparing it with axillary artery cannulation remains equivocal. This study compares outcomes of patients who underwent axillary artery and central aortic cannulation for cardiopulmonary bypass during arch surgery.

Methods

A retrospective review of 764 patients who underwent aortic arch surgery at our institution between 2005 and 2020 was performed. The primary outcome was failure to achieve uneventful recovery, defined as having experienced at least 1 of the following: in-hospital mortality, stroke, transient ischemic attack, bleeding requiring reoperation, prolonged ventilation, renal failure, mediastinitis, surgical site infection, and pacemaker or implantable cardiac defibrillator implantation. Propensity score matching was used to account for baseline differences across groups. A subgroup analysis of patients undergoing surgery for aneurysmal disease was performed.

Results

Before matching, the aorta group had more urgent or emergency operations (P = .039), fewer root replacements (P < .001), and more aortic valve replacements (P < .001). After successful matching, there was no difference between the axillary and aorta groups in failure to achieve uneventful recovery, 33% versus 35% (P = .766), in-hospital mortality, 5.3% versus 5.3% (P = 1), or stroke, 8.3% versus 5.3% (P = .264). There were more surgical site infections in the axillary group, 4.8% versus 0.4% (P = .008). Similar results were seen in the aneurysm cohort with no differences in postoperative outcomes between groups.

Conclusions

Aortic cannulation has a safety profile similar to that of axillary arterial cannulation in aortic arch surgery.

Redo mitral surgery after coronary artery bypass grafts under hyperkalemic hypothermia using thoracotomy and axillary artery cannulation in a patient with functioning bilateral internal thoracic arteries and atheromatous aorta

BACKGROUND

Redo mitral valve surgery using resternotomy after coronary artery bypass grafting (CABG) is challenging as previous CABG with patent internal thoracic artery (ITA) poses a risk of injury due to dense adhesion. It is paramount to have alternative method to minimize this risk.

CASE PRESENTATION

We report a case of redo mitral and tricuspid valve repair via right thoracotomy under hypothermia and systemic potassium administration with axillary artery cannulation in a patient after CABG with patent bilateral ITA grafts crossing over the sternum. Herein, critical dissection around the aorta and functioning ITA grafts was avoided by performing the procedure under systemic hypothermia via thoracotomy. Furthermore, considering the presence of atheroma in the aorta, the axillary artery was used as a perfusion route to prevent stroke events. Postoperative course was uneventful and echocardiography demonstrated preserved cardiac function.

CONCLUSION

Performing axillary artery cannulation and right thoracotomy under hypothermic cardiac arrest with systemic hyperkalemia without clamping the patent bilateral ITAs and aorta allowed us to perform redo mitral valve surgery after CABG without major postoperative cardiac or cerebral complications.

Contemporary utilization of the axillary artery in cardiac surgery

INTRODUCTION

The axillary artery is a reliable inflow vessel when addressing pathology of the aortic root and aortic arch that may preclude standard central cannulation strategies. This narrative review examines the use of the axillary artery in cardiac surgery. Anatomy, indications for use, cannulation strategies, and potential complications will be discussed.

METHODS

A comprehensive review of the current literature was performed using PubMed, Cochrane Review, and authoritative committee guidelines. A narrative review incorporating current available evidence was undertaken.

COMMENT

Use of the axillary artery in select cardiac surgical cases is reliable, reproducible, and may be preferable in certain cases involving ascending aortic pathology, reoperative surgery, porcelain aorta, access for transcatheter valve therapies, and peripheral mechanical circulatory support.

Validity of direct bilateral axillary arterial cannulation in emergency surgery for acute type A aortic dissection

BACKGROUND AND AIM OF THE STUDY

To assess the validity and long-term outcomes of direct bilateral axillary arterial cannulation for acute type A aortic dissection.

METHODS

Between 2003 and 2020, 208 consecutive patients with acute type A aortic dissection underwent emergency surgical repair. Cardiopulmonary bypass was attempted to establish direct bilateral axillary arterial cannulation and bicaval drainage. Antegrade selective cerebral perfusion was established by axillary perfusion and direct cannulation of the left common carotid artery.

RESULTS

Ascending aortic, partial arch, and extended total aortic arch replacement were performed in 50 (24.0%), 7 (3.4%), and 151 (72.6%) patients, respectively. Aortic root surgery and coronary artery bypass grafting were performed concomitantly in 23 and seven patients, respectively. Cardiopulmonary bypass was attempted only through bilateral axillary cannulation in all patients but was successful in 13 (6.3%) patients without bilateral axillary cannulation. No postoperative complications occurred related to this technique. There were seven hospital deaths (early mortality rate, 3.4%). Five patients had postoperative reoperation for bleeding, and nine (4.3%) were transferred to other hospitals due to postoperative permanent cerebral infarction, particularly two with arm ischemia. The 10-year survival rate of patients who underwent emergency surgical repair with this technique was 71.4%.

CONCLUSIONS

Direct bilateral axillary arterial cannulation followed by selective cerebral perfusion was successful in 93.7% of patients and this may be an optimal solution for providing stable outcomes after emergency surgery for acute type A aortic dissection. However, we experienced two complications of arm ischemia, attention should be paid to potential arm ischemia.

Comparison of Post-operative Outcomes Between Direct Axillary Artery Cannulation and Side-Graft Axillary Artery Cannulation in Cardiac Surgery: A Systematic Review and Meta-Analysis

Background

There is a growing perception of using axillary artery cannulation to improve operative outcomes in cardiopulmonary bypass surgery. Two techniques, direct cannulation or side-graft cannulation, can be used for axillary artery cannulation, but which technique is better is controversial.

Methods

A meta-analysis of comparative studies reporting operative outcomes using direct cannulation vs. side-graft cannulation was performed. We searched the PubMed, EMbase, Web of Science, and Cochrane Library. Outcomes of interest were neurological dysfunction, cannulation-related complications and early mortality. The fixed effects model was used.

Results

A total of 1,543 patients were included in the final analysis. Direct cannulation was used in 846 patients, and side-graft cannulation was used in 697 patients. Meta-analysis showed a higher occurrence of neurological Complication in direct cannulation group [odds ratio, 1.45, 95% CI (1.00, 2.10), χ² = 4.40, P = 0.05] and a significantly higher incidence of cannulation-related complications in the direct cannulation group [odds ratio, 3.12, 95% CI (1.87, 5.18), χ² = 2.54, P < 0.0001]. The incidence of early mortality did not have a difference [odds ratio, 0.95, 95% CI (0.64, 1.41), χ² = 6.35, P = 0.79].

Conclusions

This study suggests that side-graft axillary artery cannulation is a better strategy as it reduces the incidence of neurological dysfunction and cannulation-related complications.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022325456.

Cannulation strategies in aortic surgery: techniques and decision making

Arterial cannulation for cardiopulmonary bypass (CPB) is an important determinant of outcome in aortic surgery. Unlike traditional cardiac operations, aortic pathology may preclude the cannulation of the distal ascending aorta. In other cases, special need of the pathology/operation may demand an alternative cannulation site. Choosing the right cannulation site, especially in type A aortic dissection, is the most crucial initial step. The decision about cannulation sites should be individualized and patient-specific. Various cannulation techniques include femoral, right axillary, innominate, carotid, central aortic, direct true lumen, transapical, and trans-atrial left ventricle cannulation. The ideal cannulation should be easy, quick, and suitable for all clinical scenarios. It should allow smooth conduct of CPB without malperfusion or cerebral embolization. The cannulation strategy should also provide an option for selective antegrade cerebral perfusion and it should be free from neurovascular and local site complications. There is no ideal cannulation technique. Each technique has its pros and cons. Excellent results and drawbacks have been reported with each technique. Final selection of the cannulation site is dependent upon several factors. However, a surgeon's familiarity with a particular technique plays a major role in selection. Despite this, there is a definite shift in surgeons' preference from femoral to central cannulation (axillary, carotid, innominate, aortic) over the last few decades. The aim of this review is to give a brief overview of the cannulation techniques in aortic surgery and discuss the decision-making process.

Comparison of Single Axillary vs. Dual Arterial Cannulation for Acute Type a Aortic Dissection: A Propensity Score Matching Analysis

Background

The optimal arterial cannulation site for acute aortic dissection repair is unclear, especially for complex arch surgery. Axillary artery cannulation is widely accepted but adding femoral artery cannulation to it was considered to potentially improve perfusion and early outcomes. To clarify this point, a comparison of perioperative outcomes for these two different cannulation strategies was conducted regarding the pathological features of dissection.

Methods

From January 2010 to December 2019, 927 consecutive patients underwent a total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data, including detailed pathological features, were retrospectively collected and analyzed. Propensity score matching and multivariate logistic regression analysis were used for adjusting confounders that are potentially related to the outcome.

Results

A total of 523 patients (56.3%) accepted a dual arterial cannulation (DAC group), and 406 patients (43.7%) received a single axillary artery cannulation (SAC group). In total, 388 pairs of patients were well-matched. Whether before or after adjusting the preoperative characteristics by matching, there were no significant differences in operative mortality (6.7 vs. 5.4%, P = 0.420 before matching; 5.4 vs. 5.4%, P = 1 after matching), stroke (6.7 vs. 5.4%, P = 0.420 before matching; 6.4 vs. 5.2%, P = 0.435 after matching), spinal cord injury (5 vs. 5.7%, P = 0.640 before matching; 5.4 vs. 5.7%, P = 1. After matching), and acute renal failure requiring dialysis (13.8 vs. 9.6%, P =0.050 before matching; 12.6 vs. 9.5%, P = 0.174) between the two groups. Dual arterial cannulation was not an independent protective factor of operative mortality (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.55–1.86), stroke (OR 1.17, 95% CI 0.65–2.11), spinal cord injury (OR 1.17, 95% CI 0.65–2.11), and acute renal failure requiring continuous renal replacement therapy (CRRT) (OR 1.24, 95% CI 0.78–1.97) after adjusting for confounding factors by multivariable logistic regression analysis. In the subgroup analysis, no advantage of dual arterial cannulation was found for a particular population.

Conclusions

Single axillary artery cannulation was competent in the complex arch repair for acute aortic dissection, presenting with a satisfactory result as dual arterial cannulation. Adding femoral artery cannulation was necessary when a sufficient flow volume could not be achieved by axillary artery cannulation or when a lower limb malperfusion existed.

Double arterial cannulation versus right axillary artery cannulation for acute type A aortic dissection: a retrospective study

Background

Cannulation strategy in surgery for acute type A aortic dissection (ATAAD) remains controversial. We aimed to retrospectively analyze the safety and efficacy of double arterial cannulation (DAC) compared with right axillary cannulation (RAC) for ATAAD.

Methods

From January 2016 to December 2018, 431 ATAAD patients were enrolled in the study. Patients were divided into DAC group (n = 341) and RAC group (n = 90). Propensity score matching analysis was performed to compare the early and mid-term outcomes between these two groups. To confirm the organ protection effect by DAC, intraoperative blood gas results and cardiopulmonary bypass parameters were compared between the two groups.

Results

Demographics and preoperative comorbidities were comparable between two groups, while patients in DAC group were younger than RAC group (51.55 ± 13.21 vs. 56.07 ± 12.16 years, P < 0.001). DAC had a higher incidence of limb malperfusion (18.2% vs. 10.0%, P = 0.063) and lower incidence of coronary malperfusion (5.3% vs. 12.2%, P = 0.019). No significant difference in cardiopulmonary bypass and cross-clamp time was found between the two groups. The in-hospital mortality was 13.5% (58/431), while there was no difference between the two groups (13.5% vs. 13.3%; P = 0.969). Patients who underwent DAC had higher incidence of postoperative stroke (5.9% vs. 0%, P = 0.019) and lower incidence of postoperative acute kidney injury (AKI) (24.7% vs. 40.3%; P = 0.015). During a mean follow-up period of 31.8 (interquartile range, 25–45) months, the overall survival was 81.5% for DAC group and 78.0% for RAC group (P = 0.560). Intraoperative blood gas results and cardiopulmonary bypass parameters showed that DAC group had more intraoperative urine output volume than RAC group (P = 0.05), and the time of cooling (P = 0.04) and rewarming (P = 0.04) were shorter in DAC group.

Conclusions

DAC will not increase the surgical risks compared to RAC, but could reduce the incidence of postoperative AKI which may be benefit for renal protection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01714-5.

En Bloc Arch Reconstruction With the Frozen Elephant Trunk Technique for Acute Type a Aortic Dissection

Objective: The study objective was to evaluate the effect of en bloc arch reconstruction with frozen elephant trunk (FET) technique for acute type A aortic dissection.

Methods: 41 patients with acute Stanford type A dissection underwent en bloc arch reconstruction combined with FET implantation between April 2018 and August 2020. The mean age of the patients was 46 ± 13 years, and 9 patients were female. One patient had Marfan syndrome. Six patients had pericardial tamponade, 9 had pleural effusion, 5 had transient cerebral ischemic attack, and 3 had chronic kidney disease.

Results: The hospital mortality rate was 9.8% (4 patients). 2 (4.9%) patients had stroke, 23 (56.1%) had acute kidney injury, and 5 (12.2%) had renal failure requiring hemodialysis. During follow-up, the rate of complete false lumen thrombosis was 91.6% (33/36) around the FET, 69.4% (25/36) at the diaphragmatic level, and 27.8% (10/36) at the superior mesenteric artery level. The true lumen diameter at the same three levels of the descending aorta increased significantly while the false lumen diameter reduced at the two levels: pulmonary bifurcation and the diaphragm. The 1-, 2-and 3-year actuarial survival rates were 90.2% [95% confidence interval (CI), 81.2–99.2], 84.2% (95% CI, 70.1–98.3) and 70.2% (95% CI, 42.2–98), respectively.

Conclusions: In patients with acute type A dissection, en bloc arch reconstruction with FET technique appeared to be feasible and effective with early clinical follow-up results. Future studies including a large sample size and long-term follow-up are required to evaluate the efficacy.

Utility of double arterial cannulation for surgical repair of acute type A dissection

OBJECTIVES

Outcomes of planned and unplanned (rescue) double arterial cannulation (DAC) in surgery for acute type A aortic dissection were investigated retrospectively.

METHODS

The study involved 805 patients who were divided into 4 groups according to the cannulation strategy: single cannulation of the femoral artery (n = 338), axillary artery (n = 256), left ventricular apex (n = 52) or ascending aorta (n = 5) (total, n = 57), and DAC (n = 154). Patients who underwent DAC were divided between planned (n = 132) and rescue (n = 22) usage. Characteristics and outcomes were compared between groups. Both unmatched and propensity score-matched analyses were performed.

RESULTS

Shock (39%, 19%, 33% and 14%, in the femoral artery, axillary artery, left ventricular apex/ascending aorta and DAC, respectively) and leg malperfusion (5%, 16%, 16% and 26%, respectively) differed significantly (P < 0.001), but in-hospital mortality did not (9%, 8%, 18% and 7%, respectively; P = 0.096). The 5-year survival rates were 79.4%, 79.7%, 78.6% and 82.2%, respectively. Propensity score-matched analysis showed no statistically significant differences in in-hospital mortality rates (10%, 12%, 14% and 9%, respectively; P = 0.78) and 5-year survival rates (78.4%, 72.3%, 82.3% and 78.0%, respectively). The leading vessel combination and indications for planned and rescue DAC were the femoral and axillary arteries (98%) and true lumen narrowing and/or leg malperfusion (34%), and the axillary followed by femoral (77%) artery and low cardiopulmonary bypass flow (36%). In-hospital mortality in the planned and rescue DAC groups was 7% and 9%, respectively.

CONCLUSIONS

DAC seems effective for both prevention and management of intraoperative malperfusion.

Seven arterial aneurysms with an acute type A aortic dissection

BACKGROUND

Multiple arterial aneurysms are often seen in the elderly and are caused mainly by atherosclerosis.

A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery

BACKGROUND

Cerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy.

OBJECTIVE

To compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery.

METHODS

This randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, ClinicalTrials.gov Identifier: NCT02554032), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke.

RESULTS

One hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups.

CONCLUSIONS

diffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.

Combined femoral and axillary perfusion strategy for Stanford type a aortic dissection repair

Background

The optimal cannulation strategy in surgery for Stanford type A aortic dissection is critical to patient survival but remains controversial. Different cannulation strategies have their own advantages and drawbacks during cardiopulmonary bypass. Our centre used a combined femoral and axillary perfusion strategy for the surgical treatment of type A aortic dissection. The purpose of this study was to review and clarify the clinical outcome of femoral artery cannulation combined with axillary artery cannulation for the treatment of Stanford type A aortic dissection.

Methods

We performed a retrospective study that included 327 patients who were surgically treated for type A aortic dissection in our institution from January 2017 to June 2019. Femoral and axillary artery cannulation was used to establish cardiopulmonary bypass in patients with type A aortic dissection. The demographic data, surgical data, and clinical results of the patients were calculated.

Results

Femoral artery combined with axillary artery cannulation was technically successful in 327 patients. The cardiopulmonary bypass time was 141.60 ± 34.89 min, and the selective antegrade cerebral perfusion time was 14.94 ± 2.76 min. The early mortality rate was 3.06%. The incidence of permanent neurologic dysfunction was 0.92%. Sixteen patients had postoperative renal insufficiency, and five patients had liver failure.

Conclusion

Femoral artery combined with axillary artery cannulation for type A aortic dissection can significantly improve the prognosis of patients, especially in terms of cerebral protection, and can reduce the occurrence of adverse malperfusion syndrome and neurological complications.

Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies

Acute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.

Usefulness of routine use of bilateral axillary artery perfusion in total arch replacement

OBJECTIVES

To avoid cerebral infarction for aortic arch aneurysm and malperfusion for acute aortic dissection, the site of cannulation during total arch replacement remains important. Recently, we have used bilateral axillary artery perfusion in total arch replacement and in acute aortic dissection. Herein, we report the surgical outcomes.

METHODS

Seventy-eight patients with aortic arch aneurysm and 45 patients with acute aortic dissection were enrolled in this study. During surgery, translocation of the total arch was performed on 67 patients using a 'frozen elephant trunk technique'.

RESULTS

In patients with aortic arch aneurysm, there was no postoperative cerebral infarction. New postoperative cerebral infarction was observed in only one patient who underwent acute aortic dissection. Two patients who had aortic arch aneurysm and 2 patients who had acute aortic dissection died at the hospital. Complications related to bilateral axillary perfusion were not observed.

CONCLUSIONS

The routine use of bilateral axillary artery perfusion in total arch replacement for aortic arch aneurysm to avoid cerebral infarction has the potential to be a useful procedure. It can facilitate the frozen elephant trunk procedure in acute aortic dissection.

Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database

OBJECTIVES

Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to examine the incidence and factors associated with acute stroke following type A repair.

METHODS

Acute type A aortic dissection repairs performed from 2014 to 2017 were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The effect of cannulation strategy (eg, axillary, femoral, direct, or innominate), lowest temperature, cerebral protection techniques (antegrade cerebral profusion, retrograde cerebral perfusion, both, or none), repair technique, and institutional volume on postoperative stroke was investigated.

RESULTS

Acute type A repair was performed on 8937 patients at 772 centers, of which 7353 met inclusion criteria. Operative mortality was 17% and incidence of postoperative stroke was 13%. Axillary cannulation was associated with lower risk of stroke versus femoral (odds ratio, 0.60; P < .001). Retrograde cerebral perfusion was associated with reduced risk for stroke compared with no cerebral perfusion (odds ratio, 0.75; P = .008) or antegrade cerebral perfusion (odds ratio, 0.75; P = .007). Total arch replacement was associated with greater risk for stroke versus hemiarch technique (odds ratio, 1.30; P = .013). Longer circulatory arrest time, cerebral perfusion time, and cardiopulmonary bypass time were all related to higher risk of postoperative stroke.

CONCLUSIONS

Stroke is a common complication after type A repair. Axillary cannulation was associated with lower incidence of stroke, whereas femoral cannulation significantly increased the risk of stroke regardless of the cerebral perfusion strategy or the degree of hypothermia. Retrograde cerebral profusion was found to have reduced risk for postoperative stroke. Degree of hypothermia and center volume were not related to stroke incidence.

Samurai cannulation (direct true-lumen cannulation) for acute Stanford Type A aortic dissection

OBJECTIVES

In this study, we investigated early outcomes of patients who underwent surgical aortic repair for acute Stanford Type A aortic dissection at the Kitasato University Hospital and compared the results of Samurai cannulation (direct true-lumen cannulation) with other cannulation options.

METHODS

Inpatient and outpatient records were retrospectively reviewed.

RESULTS

Among the 100 patients who were operated on for acute Type A aortic dissection between April 2011 and April 2017, sole Samurai cannulation was used in 61 patients (Group S) and other cannulation options were used in the remaining 39 patients (Group O). No significant difference was observed in preoperative demographics between the groups. True-lumen cannulation was successful in all Group S patients, whereas 3 cannulation-related complications were observed in Group O patients. In Group S, the 30-day and in-hospital mortality occurred in 3 (5%) and 4 (7%) patients, respectively, and in Group O, these occurred in 3 (8%), and 6 (15%) patients, respectively. Four patients in each group (7% and 10%) experienced disabling or fatal strokes. Early mortality or stroke rate between the groups were not significantly different. During follow-up, there was no statistically significant difference between the groups in terms of survival, freedom from aorta-related death or freedom from aortic events.

CONCLUSIONS

Early outcomes of the initial series of surgery for Stanford Type A aortic dissection with Samurai cannulation was favourable with acceptable mortality and stroke rates without cannulation-related complications. Samurai cannulation represents an easy, safe and reasonable option for cardiopulmonary bypass in surgery for acute Stanford Type A aortic dissection.

Is Axillary Better Than Femoral Artery Cannulation in Repair of Acute Type A Aortic Dissection?

Objective

We compared early and late outcomes of patients who underwent femoral versus axillary artery cannulation for repair of acute type A aortic dissection.

Methods

Between 2004 and 2017, we retrospectively evaluated the clinical outcomes of 135 consecutive patients who underwent emergency surgery for acute type A aortic dissection repair. Patients were divided into 2 groups: those who underwent femoral ( n = 84) and those who underwent right axillary ( n = 51) artery cannulation. Mean patient age was 63 ± 13 years and 88 (65%) were male.

Results

Overall operative mortality was 12.6% (axillary 15.7%, femoral 10.7%; P = 0.564). Patients who underwent axillary compared to femoral artery cannulation had a statistically nonsignificant higher operative mortality rate among both stable and unstable patients (13% vs. 6.5%, P = 0.405 and 40% vs. 22.7%, P = 0.818, respectively). While there was no difference in major complication rates, such as stroke, low cardiac output, and surgical revision for bleeding/tamponade, there was a higher incidence of renal failure that required dialysis in patients who underwent axillary cannulation (12% vs. 1%, P = 0.022). Multivariate analysis demonstrated that predictors for the composite endpoint of operative mortality or severe organ malperfusion, such as renal failure or cerebrovascular accident, were hemodynamic instability on admission (OR 3.87; 95% CI, 1.23 to 12.63; P = 0.021), lower preoperative creatinine clearance (OR 0.94; 95% CI, 0.90 to 0.97; P < 0.001); and the use of axillary artery cannulation (OR 4.1; 95% CI, 1.43 to 12.78; P = 0.011). Among those discharged from hospital, the 3-year survival rate was 91% in the axillary group and 87% in the femoral group ( P = 0.772).

Conclusions

Based on our experience, emergent surgery for both stable and unstable patients with acute type A aortic dissection demonstrated similar survival rates and significantly less renal impairment when using the femoral cannulation approach.

Double arterial cannulation strategy for acute type A aortic dissection repair: A 10-year single-institution experience

Background

Repair of acute type A aortic dissection (ATAAD) is a complex and emergent cardiovascular surgery that is associated with high perioperative morbidity and mortality. Each cannulation strategy has different benefits and drawbacks during cardiopulmonary bypass. Using a retrospective study design, we aimed to clarify the safety and efficacy of right axillary artery cannulation in combination with femoral artery cannulation compared to single arterial cannulation for ATAAD repair.

Methods

From January 2007 to July 2017, 476 adult patients underwent ATAAD repair at a single institution. Patients were classified into groups according to their cannulation strategy: the double arterial cannulation (DAC) group (n = 377; 79.2%) or single arterial cannulation (SAC) group (n = 99; 20.8%). Preoperative demographics, surgical information, and postoperative recovery were compared between both groups. Survival and freedom from reoperation rates were analyzed using the Kaplan-Meier actuarial method.

Results

Demographics, comorbidities, and surgical procedures were generally homogenous between the two groups, except for sex, age, and rate of extensive aortic repair. Patients who underwent DAC had lower in-hospital mortality (13.5% vs. 25.3%; P = 0.005) and lower incidence of malperfusion-related complications (18.8% vs. 30.3%; P = 0.011) than those who underwent SAC. During multivariate analysis, SAC was identified as an in-hospital mortality predictor (odds ratio, 2.81; 95% confidence interval, 1.52–5.17; P = 0.001), as were preoperative ventilator support, intraoperative extracorporeal membrane oxygenation installation, and postoperative malperfusion-related complications. Three-year cumulative survival and freedom from reoperation rates were 74.8% and 85.3% for the DAC group and 62.6% and 81.1% for the SAC group, respectively (P = 0.010 and 0.430, respectively).

Conclusions

With acceptable short- and mid-term outcomes, DAC is effective and safe for establishing cardiopulmonary bypass during ATAAD repair.

Innominate Versus Axillary Artery Cannulation for the Hemiarch Repair

BACKGROUND

Innominate artery cannulation has gained some popularity over the last decade as an alternative to axillary artery cannulation for providing selective antegrade cerebral perfusion during repair of the ascending aorta and arch. Innominate artery cannulation provides several advantages including avoidance of an additional incision and use of a larger caliber artery to provide less resistance to high flow during bypass and selective antegrade cerebral perfusion. We hypothesize that these advantages make innominate artery cannulation superior to axillary artery cannulation as it can decrease operative times and potentially decrease blood loss.

METHODS

This was a single-center retrospective analysis of 206 patients who underwent hemiarch replacement between 2009 and 2017. All patients qualified including emergent cases. Groups were separated by mode of cannulation: axillary and innominate. Outcomes evaluated included cardiopulmonary bypass (CPB) time, cross-clamp time, circulatory arrest (CA) time, postoperative transfusions, intensive care unit length of stay, development of any neurological complications, end-organ failure, and mortality. Subgroup analysis was performed for elective and emergent cases.

RESULTS

Axillary and innominate artery cannulation accounted for 37% (n = 77) and 67% (n = 129) of cases, respectively. There was no difference in patient characteristics except for a higher incidence of renal disease in the axillary group (16% versus 6%, P = 0.05). More emergent cases were performed in the axillary group (61% versus 17%, P < 0.001). Innominate cases had shorter CPB times (189 versus 150 min, P < 0.001) and CA (22.5 versus 11 min, P < 0.001) times overall. In the elective subgroup, CA times were shorter for the innominate cases. However, the emergent subgroup displayed no difference in operative times. Less transfusions were given in the innominate group including units of red blood cells (2 [0-6] versus 0 [0-2], P < 0.001), units of platelets (2 [1-3] versus 1 [0-2], P = 0.001), and units of plasma (6 [2-9] versus 2 [0-4], P < 0.001). A similar trend was observed in the elective subgroup. No difference in transfusions was observed in the emergent subgroup. There was no statistical difference in remaining outcomes between cases of axillary and innominate cannulation in the combined, elective, and emergent groups.

CONCLUSIONS

Alternate cannulation strategies for open arch anastomoses are evolving with a trend toward using the innominate artery. These data suggest that innominate cannulation is at least equivalent to, and may be superior to, axillary cannulation. The innominate artery provides a larger conduit vessel for perfusion and this decrease in resistance to flow, allowing for faster cooling and rewarming, maybe why CPB times were lower in this group. Innominate cannulation is a safe and potentially advantageous technique for hemiarch repair.

Fenestrated TEVAR Using a Guidewire Fixator for Anchoring in Aortic Arch Target Vessels

Purpose: To report a new facilitated method for securing target vessel access during single fenestrated and branched thoracic endovascular repair using a guidewire fixator. Technique: The Liungman Guidewire Fixator (LGF) includes a 0.035-inch guidewire that is fitted with a stopper close to the distal end and a self-expanding anchoring element that is freely movable over the guidewire to the point of the stopper. The technique of using a LGF for anchoring in a target vessel is described in a 75-year-old woman with a 53-mm saccular arch aneurysm. She was treated with a fenestrated Zenith stent-graft that had a catheter-preloaded fenestration for the left subclavian artery (LSA) and a scallop for the left common carotid artery. To avoid through-and-through wire and brachial access, the LGF was used to secure the guidewire in the LSA during stent-graft deployment. Conclusion: The use of an LGF for anchoring in the target LSA during fenestrated arch endografting was feasible and safe.

Axillary versus innominate artery cannulation for antegrade cerebral perfusion in aortic surgery: design of the Aortic Surgery Cerebral Protection Evaluation (ACE) CardioLink-3 randomised trial

INTRODUCTION

Neurological injury remains the major cause of morbidity and mortality following open aortic arch repair. Systemic hypothermia along with antegrade cerebral perfusion (ACP) is the accepted cerebral protection approach, with axillary artery cannulation being the most common technique used to establish ACP. More recently, innominate artery cannulation has been shown to be a safe and efficacious method for establishing ACP. Inasmuch as there is a lack of high-quality data comparing axillary and innominate artery ACP, we have designed a randomised, multi-centre clinical trial to compare both cerebral perfusion strategies with regards to brain morphological injury using diffusion-weighted MRI (DW-MRI).

METHODS AND ANALYSIS

110 patients undergoing elective aortic surgery with repair of the proximal arch requiring an open distal anastamosis will be randomised to either the innominate artery or the axillary artery cannulation strategy for establishing unilateral ACP during systemic circulatory arrest with moderate levels of hypothermia. The primary safety endpoint of this trial is the proportion of patients with new radiologically significant ischaemic lesions found on postoperative DW-MRI compared with preoperative DW-MRI. The primary efficacy endpoint of this trial is the difference in total operative time between the innominate artery and the axillary artery cannulation group.

ETHICS AND DISSEMINATION

The study protocol and consent forms have been approved by the participating local research ethics boards. Publication of the study results is anticipated in 2018 or 2019. If this study shows that the innominate artery cannulation technique is non-inferior to the axillary artery cannulation technique with regards to brain morphological injury, it will establish the innominate artery cannulation technique as a safe and potentially more efficient method of antegrade cerebral perfusion in aortic surgery.

TRIAL REGISTRATION NUMBER

NCT02554032.

Intraoperative care for aortic surgery using circulatory arrest

The total circulatory arrest (CA) is necessary to achieve optimal surgical conditions in certain aortic pathologies, especially in those affecting the ascending aorta and aortic arch. During this procedure it is necessary to protect all the organs of ischemia, especially those of the central nervous system and for this purpose several strategies have been developed. The first and most important protective method is systemic hypothermia. The degree of hypothermia and the route of application have been evolving and currently tend to use moderate hypothermia (MH) (20.1-28 °C) associated with unilateral or bilateral selective cerebral perfusion methods. In this way the neurological results are better, the interval of security is greater and the times of extracorporeal circulation are smaller. Even so, it is necessary to take into account that there is the possibility of ischemia in the lower part of the body, especially of the abdominal viscera and the spinal cord, therefore the time of circulatory stop should be limited and not to exceed 80 minutes. Evidence of possible neurological drug protection is very weak and only mannitol, magnesium, and statins can produce some benefit. Inhalational anesthetics and some intravenous seem to have advantages, but more studies would be needed to test their long-term benefit. Other important parameters to be monitored during these procedures are blood glucose, anemia and coagulation disorders and acid-base balance. The recommended monitoring is common in complex cardiovascular procedures and it is of special importance the neurological monitoring that can be performed with several techniques, although currently the most used are Bispectral Index (BIS) and Near-Infrared Spectroscopy (NIRS). It is also essential to monitor the temperature routinely at the nasopharyngeal and bladder level and it is important to control coagulation with rotational thromboelastometry (ROTEM).

Subclavian artery cannulation provides better myocardial protection in conventional repair of acute type A aortic dissection: experience from a single medical centre in Taiwan

Background

Although many reports have detailed the advantages and disadvantages between femoral and subclavian arterial cannulations for acute aortic dissection type A (AADA), the confounding factors caused by disease severity and surgical procedures could not be completely eliminated. We compared femoral and subclavian artery cannulation and report the results for reconstruction of only the ascending aorta.

Methods

From January 2003 to December 2010, 51 AADA cases involving reconstruction of only the ascending aorta were retrospectively reviewed and categorised on the basis of femoral (n = 26, 51%) or subclavian (n = 25, 49%) arterycannulation. Bentall’s procedures, arch reconstruction and hybrid operations with stent-grafts were all excluded to avoid confounding factors due to dissection severity. Surgical results, postoperative mortality, and short- and mid-term outcomes were compared between the groups.

Results

Subclavian cannulation had a lower incidence of cerebral and myocardial injury and lower hospital mortality than femoral cannulation (8 vs 34%, p = 0.04). Ventilation duration as well as intensive care unit (ICU) and hospital stay were also shorter with subclavian cannulation. Risk factors for hospital mortality included pre-operative respiratory failure (odds ratio: 12.84), peri-operative cardiopulmonary bypass (CPB) time > 200 minutes (odds ratio: 13.49), postoperative acidosis (pH < 7.2, odds ratio: 88.63), and troponin I > 2.0 ng/ml (odds ratio: 20.08). The overall hospital mortality rate was 21%. The 40 survivors were followed up for three years with survival of 75% at one year and 70% at three years.

Conclusions

Our results show that subclavian cannulation had a lower incidence of cerebral and myocardial injury as well as better postoperative recovery and lower hospital mortality rates for reconstruction of only the ascending aorta.

Axillary Versus Femoral Arterial Cannulation During Repair of Type A Aortic Dissection?: An Old Problem Seeking New Solutions

BACKGROUND

The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute Type A aortic dissection with axillary or femoral artery cannulation.

METHODS

A total of 305 patients from five academic medical centers underwent acute Type A aortic dissection repair via axillary (n = 107) or femoral (n = 198) artery cannulation between January 2000 and December 2010. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality, and Cox regression hazard ratios were calculated to determine predictors of long-term mortality.

RESULTS

Operative mortality was not influenced by cannulation site (16% for axillary cannulation vs. 19% for femoral cannulation, p = 0.64). In multivariate logistic regression analysis, hemodynamic instability (p < 0.001) and prolonged cardiopulmonary bypass time (>200 min; p = 0.05) emerged as independent predictors of operative mortality. Stroke rates were comparable between the two techniques (14% for axillary and 17% for femoral cannulation, p = 0.52). Five-year actuarial survival was comparable between the groups (55.1% for axillary and 65.7% for femoral cannulation, p = 0.36). In Cox regression analysis, predictors of long-term mortality were: age (p < 0.001), stroke (p < 0.001), prolonged cardiopulmonary bypass time (p = 0.001), hemodynamic instability (p = 0.002), and renal failure (p = 0.001).

CONCLUSIONS

The outcomes of femoral versus axillary arterial cannulation in patients with acute Type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles.

Knowledge, attitudes, and practice preferences of Canadian cardiac surgeons toward the management of acute type A aortic dissection

OBJECTIVES

The complexity of surgical treatment for acute type A dissection contributes to the variability in patient management. This study was designed to elucidate the contemporary practice preferences of cardiac surgeons regarding different phases of management of acute type A aortic dissection.

METHODS

A 34-item questionnaire was distributed to all Canadian adult cardiac surgeons addressing the preoperative, intraoperative, and postoperative management of acute type A dissection. A total of 100 responses were obtained (82% of active surgeons in Canada). Outcomes were compared between high- and low-volume aortic surgeons.

RESULTS

Seventy-six percent of respondents favored axillary artery cannulation. High-volume surgeons (>150 cases) were more likely to indicate a target lowest nasopharyngeal temperature more than 20 °C (53% vs 25%, P = .02). The majority of surgeons (65%) recommended using selective antegrade cerebral perfusion, with a significantly greater proportion for higher-volume aortic surgeons (P = .03). In addition, high-volume aortic surgeons were more likely to recommend aortic root replacement at smaller diameters (73% vs 55%, P = .02), to recommend more extensive distal aortic resection with routine open hemiarch anastomosis (85% vs 65%, P = .04), and to more commonly perform total arch reconstruction when needed (93% vs 77%, P = .04). In the follow-up period, frequency of serial imaging of the residual aorta was significantly higher for high-volume aortic surgeons (P = .04).

CONCLUSIONS

This study identified some commonalities in practice preferences among Canadian cardiac surgeons for the management of acute type A aortic dissection. However, it also highlighted significant differences in temperature management, cerebral protection strategies, and extent of resection between high-volume and low-volume aortic surgeons.

Axillary versus femoral arterial cannulation in type A acute aortic dissection: evidence from a meta-analysis of comparative studies and adjusted risk estimates

OBJECTIVES

There is a growing perception that femoral arterial cannulation (FAC), by reversing the flow in the thoracoabdominal aorta, may increase the risk of retrograde brain embolization, dissection and organ malperfusion in type A aortic dissection. Axillary artery cannulation (AXC) has been reported to improve operative outcomes by allowing antegrade blood flow. However, FAC still remains largely utilized as a consensus for the routine use of AXC has not yet been reached.

METHODS

A meta-analysis on comparative studies reporting operative outcomes using AXC versus FAC was performed. Pooled weighted incidence rates for end points of interest (both adjusted and unadjusted) have been computed using an inverse variance model.

RESULTS

Overall, a total of 8 studies including 793 patients were analysed (AXC = 396, FAC = 397). AXC was associated with reduced risk for in-hospital mortality [risk ratio (RR): 0.41; 95% confidence interval (CI): 0.29-0.58; P < 0.001] and permanent neurological deficit (PND) (RR: 0.59; 95% CI: 37.-0.93; P = 0.02) when compared with FAC. Pooled adjusted estimates confirmed that AXC was independently associated with a significantly reduced incidence of in-hospital mortality (adjusted OR: 0.54; 95% CI: 0.36-0.82; P = 0.004; I(2) = 57%) and PND (adjusted OR: 0.19; 95%CI: 0.07-0.54; P = 0.002; I(2) = 0%).

CONCLUSIONS

The present meta-analysis demonstrated that AXC is superior to FAC in reducing in-hospital mortality and the incidence of PND in patients operated on for type A acute aortic dissection.

Central cannulation by Seldinger technique: a reliable method in ascending aorta and aortic arch replacement

Background

Extensive type A aortic dissections that involve peripheral great vessels can complicate the choice of a cannulation site for cardiopulmonary bypass. We started to employ direct cannulation of the true lumen on the concavity of the aortic arch by Seldinger technique and evaluated the efficacy of this access technique as an alternative arterial inflow target in aortic surgery.

Material/Methods

Twenty-four consecutive patients (mean age: 59±14 years) underwent type A aortic dissection repair using selective antegrade cerebral perfusion. Direct aortic cannulation was used in 14 cases, subclavian access in 6 patients, and femoral entry in 4 patients. Perioperative factors were evaluated to identify the reliability and eventual benefits of direct cannulation method at the aortic arch.

Results

There were no operative deaths and cumulative 30-day mortality rate was 25% (6). Permanent neurological deficits were not observed; in 1 patient transient changes occurred (4%). Time to reach circulatory arrest was the shortest in the direct access group, with mean 27±11 (CI: 20.6–33.3) min vs. 43±22 (28.0–78.0) min (p=0.058) and 32±8 (23.6–40.4) min (p=0.34) by femoral cannulation and subclavian entry, respectively. Direct arch cannulation resulted in the best renal function in the first 72 h after surgery and similar characteristics were observed in lactic acid levels.

Conclusions

Ultrasound-guided direct cannulation on the concavity of the aortic arch using a Seldinger technique is a reliable method in dissection repairs. Prompt antegrade perfusion provides not only cerebral but also peripheral organ and tissue protection, which is an advantage in this high-risk group of patients.

The role of transapical cannulation in the operative management of acute aortic dissection

OBJECTIVES

The aim of the study was to investigate the usefulness of transapical cannulation as the routine cannulation site in patients with acute aortic dissection and to compare it with other cannulation methods.

METHODS

Between January 2010 and December 2013, emergency surgery was performed in 111 consecutive patients with acute type A aortic dissection. Patients were divided into two groups: transapical cannulation group and other cannulation sites group (including femoral and axillary artery cannulation). Pre-, intra- and postoperative data were compared between these two groups of patients.

RESULTS

Transapical cannulation was the most frequent cannulation site (78 patients, 70.3%), the femoral artery was selected in 24 patients (21.6%) and the axillary artery in 9 patients (8.1%). The mortality rate in the transapical group was 16.7% and 18.2% when other cannulation sites were chosen (p=0.85). No difference in postoperative stroke rate (6.4% vs 9.1%, p=0.62, transapical vs other cannulation sites group, respectively), myocardial infarction (6.4% vs 6.1%, p=0.94) and postoperative acute renal insufficiency incidence (9% vs 6.1%, p=0.61) was found.

CONCLUSIONS

Routine transapical cannulation in patients with acute type A aortic dissection is a fast and safe way to establish cardiopulmonary bypass. There is no difference in major operative outcomes after transapical cannulation when compared to the other cannulation sites.

Direct innominate artery cannulation for selective antegrade cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery

OBJECTIVE

To demonstrate a novel, reproducible, and effective method of direct innominate artery cannulation using a 14 F pediatric venous cannula to establish antegrade cerebral protection (ACP) in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement.

METHODS

We reviewed prospectively gathered data on all patients who had undergone replacement of the ascending aorta or hemiarch with an open distal anastomosis using deep hypothermic circulatory arrest and direct innominate artery cannulation with a 14 F pediatric venous cannula at our institution. After central cannulation and cooling to 25 °C to 28 °C, all patients had ACP initiated by way of a direct innominate cannula placed over a guidewire.

RESULTS

Fifty patients underwent direct innominate artery cannulation with our technique from 2010 to 2012. The operative mortality was 2% (n = 1), and the rates of neurologic morbidity were acceptable and similar to those with other methods of ACP delivery: stroke (2%, n = 1), seizure (0%, n = 0), and delirium (18%, n = 9). The mean operative time was 31 ± 9, 19 ± 5, 100 ± 39, 141 ± 39, and 259 ± 63 minutes for cooling, circulatory arrest, crossclamp, cardiopulmonary bypass, and total operative time, respectively. No local or arterial complications were observed.

CONCLUSIONS

Direct cannulation of the innominate artery using a 14 F pediatric venous cannula is a simple, reproducible, safe, and effective technique for establishing ACP in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement. This technique avoids the additional time and potential local complications associated with other established methods for delivering ACP, such as axillary cannulation.

Efficacy of right axillary artery perfusion for antegrade cerebral perfusion in open total arch repair

OBJECTIVE

Right axillary artery (RAxA) perfusion was introduced for selective antegrade cerebral perfusion in total aortic arch repair to prevent cerebral embolism derived from arterial cannulation. However, the strategic benefits and long-term results regarding the cannulation site remain controversial. We retrospectively compared the outcomes between propensity score-matched patients with and without using RAxA cannulation.

METHODS

Between 2006 and 2012, 260 consecutive patients underwent total arch repair with antegrade cerebral perfusion and moderate hypothermia at a single institution. RAxA cannulation was added in 142 patients (54.6%), and 70 propensity score-matched pairs were obtained.

RESULTS

There were no significant differences in 30-day (2.9% [2 of 70] vs 5.7% [4 of 70]; P = .415 and in-hospital death (5.7% [4 of 70] vs 5.7% [4 of 70]; P = 1.000) between matched pairs. Although there was no significant difference in the occurrence of postoperative stroke (8.6% [6 of 70] vs 8.6% [6 of 70]; P = 1.000), the new rate of new occurrence of postoperative paraparesis was lower in patients with RAxA perfusion (0% [0 of 70] vs 4.3% [3 of 70]; P = .067). With a mean follow-up period of 1057 ± 686 days, the overall 5-year survival was 90.6% and was 89.6% for patients with RAxA perfusion. Thee difference in survival between patients with and without RAxA perfusion was not significant.

CONCLUSIONS

RAxA perfusion is a useful option for total aortic arch repair, and the midterm outcomes were satisfactory. However, RAxA perfusion did not completely prevent stroke in patients with an atherothrombotic aorta.