Axillary Artery Cannulation in Acute Aortic Dissection: A Word of Caution

Extra-anatomic revascularization and a new cannulation strategy for preoperative cerebral malperfusion due to severe stenosis or occlusion of supra-aortic branch vessels in acute type A aortic dissection

Objectives

Acute type A aortic dissection (ATAAD) with severe stenosis or occlusion of the true lumen of aortic arch branch vessels often leads to an increased incidence of severe postsurgical neurological complications and mortality rate. In this study, we aimed to introduce our institutional extra-anatomic revascularization and cannulation strategy with improved postoperative outcomes for better management of patients with cerebral malperfusion in the setting of ATAAD.

Methods

Twenty-eight patients with ATAAD complicated by severe stenosis or occlusion of the aortic arch branch vessels, as noted on combined computed tomography angiography of the aorta and craniocervical artery, between January 2021 and June 2022 were included in this study. Basic patient characteristics, surgical procedures, hospitalization stays, and early follow-up results were analyzed.

Results

The median follow-up duration was 16.5 months (interquartile range: 11.5-20.5), with a 100% completion rate. The 30-day mortality rates was 7.1% (2/28 patients); two patients had multiple cerebral infarctions on preoperative computed tomography and persistent coma. Postoperative transient neurological dysfunction occurred in 10.7% (3/28) of the patients, and no new permanent neurological dysfunction occurred. Of all the patients, 3.6% (1/28) had novel acute renal failure. No other deaths, secondary surgeries, or serious complications occurred during the early follow-up period.

Conclusions

Use of extra-anatomic revascularization and a new cannulation strategy before cardiopulmonary bypass is safe and feasible and may reduce the high incidence of postoperative neurological complications in patients with ATAAD and cerebral malperfusion.

sArterial cannulation to establish cardiopulmonary bypass during surgery for acute aortic dissection

A cannulation strategy in surgery for Stanford type A acute aortic dissection (AAAD) is integral for patient survival. Femoral cannulation has been the standard option for cannulation; however, there is increasing evidence that retrograde perfusion with femoral cannulation is associated with worse clinical outcomes, and new cannulation sites have been introduced in surgery for AAAD. Although axillary artery cannulation and central cannulation via the ascending aorta have become more popular than femoral access in recent years, adverse events have been reported and shifting cannulation sites during surgery are recommended by some surgeons. Therefore, it is beneficial for surgeons to broaden their knowledge about cannulation technology for AAAD. In this review, we discuss the various methods of cannulation for AAAD.

Be Aware of Aberrant Right Subclavian Artery Origin Before Aortic Coarctation Stenting: A Case Report Study

The subclavian steal syndrome (SSS), also called subclavian steal steno-occlusive disease, is defined as reversal of the vertebral artery flow secondary to significant hemodynamically ipsilateral occlusion or stenosis of the proximal subclavian artery. It is usually seen secondary to atherosclerosis and aberrant right subclavian artery (ARSA), resulting in SSS which is even less common. Aberrant right subclavian artery is a kind of vascular anomaly associated with coarctation of the aorta (CoA). It usually originates from the descending aorta distal to the site of CoA. Here, we present a young man who was a case of ARSA and CoA. He developed SSS after transcatheter aortic stenting secondary to unusual origin of ARSA from the site of CoA. Awareness of this rare anomaly helps to overcome this complication in patients undergoing interventional stenting for CoA and ARSA with anomalous origin.

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.