Direct Axillary Artery Cannulation for Type A Dissection and Impact of Dissected Innominate Artery

Direct Axillary Artery Cannulation as Standard Perfusion Strategy in Minimally Invasive Coronary Artery Bypass Grafting

OBJECTIVE

Cardiopulmonary bypass (CPB) via the right axillary artery (RAA) has become an alternative perfusion strategy, especially in complex aortic procedures. This study delineates our technique and outcome with direct axillary cannulation utilizing the Seldinger technique, which we adopted as the standard perfusion strategy in the sternum-sparing minimally invasive total coronary revascularization via left anterior thoracotomy (TCRAT) using CPB.

METHODS

From November 2019 to December 2023, a total of 413 consecutive patients underwent nonemergent isolated coronary artery bypass grafting (CABG) via left anterior minithoracotomy on CPB with peripheral cannulation via the RAA and cardioplegic cardiac arrest, using this technique as a default strategy in the daily routine. All patients had multivessel coronary artery disease. The primary outcome was intraoperative cannulation-related complications (bleeding, revision, ischemia, wound healing complications). The secondary outcome was cannulation-related events during follow-up (blood pressure differences, incidence of brachial plexus injury, clinical signs of circulatory problems of arm and hand, re-interventions). Mean midterm follow-up was 18.7 ± 12.3 [1.1-51.2] months. During follow-up, 16 patients died. Overall, a total of 397 patients (344 male; 67.6 ± 9.7 [32-88]) were included for follow-up (100%).

RESULTS

The RAA was successfully cannulated in 100% of patients. A cannula size of 16 Fr was used in 34.6%, 18 Fr in 63.9% and 20 Fr in 1.5% of all patients. There was no intraoperative bleeding complication. In two patients, intraoperative revision of the RAA was required, necessitating a venous patch repair. At follow-up, there were no differences between the systolic and diastolic blood pressure or the pressure gradients between the right and left arm. Transient numbness of the right hand was observed in two patients. Permanent numbness was not observed. No patient needed further intervention or surgical revision of the RAA.

CONCLUSIONS

The right axillary cannulation is feasible and safe in terms of vascular injury and brachial plexus injury with excellent in-hospital and follow-up outcome.

Comparison of clinical outcomes between double arterial cannulation and single arterial cannulation in type A aortic dissection

It remains controversial as to which optimal cannulation strategy ought to be employed in surgery for type A aortic dissection (TAAD). The aim of this study was to make a comparison of the clinical outcomes between single and double arterial cannulation. From January 2018 to December 2022, 403 individuals with TAAD were recruited for the study and were divided into two groups based on the cannulation approach. A total of 206 patients underwent single arterial cannulation, while 197 patients underwent double arterial cannulation. In order to balance the data encompassing specific pathological traits, stabilized inverse probability weighting (IPTW) was utilized. Confounding variables that could potentially be associated with the outcomes were adjusted by means of multivariate logistic regression analysis with IPTW. There was a significant difference in in-hospital mortality (19.9% versus 9.1% for single versus double arterial cannulation, respectively, P < 0.01). The incidence of stroke and acute kidney injury requiring dialysis was lower in the double arterial cannulation group than in the single artery cannulation group, but there was no statistical difference. Compared with the single arterial cannulation cohort, the IPTW adjusted odds ratios for in-hospital mortality and stroke in the double arterial cannulation cohort were 0.436 (95% CI, 0.211-0.903, P < 0.01) and 0.52 (95% CI, 0.3-0.89, P = 0.017), respectively. Double arterial cannulation served as a protective factor for in-hospital mortality and stroke. Consistent findings were noted upon stratification based on age, sex, BMI, and the duration of cardiopulmonary bypass. By providing stable systemic organ perfusion, the establishment of CPB with DAC can constitute a safe technique for TAAD repair.

Right axillary artery cannulation in acute type A aortic dissection with involvement of the right axillary artery

OBJECTIVE

The right axillary artery is currently recommended for arterial cannulation in surgery for acute type A aortic dissection. However, the feasibility of cannulation on a dissected right axillary artery remains undetermined. The objective was to examine the feasibility of cannulation on a dissected right axillary artery.

METHODS

From 2016 to 2020, 835 patients who underwent acute type A aortic dissection repair were included in this study. Cannulation strategy and perioperative outcomes of patients who did and did not have right axillary artery dissection were compared. Propensity score matching and logistic regression were applied.

RESULTS

A total of 124 patients had right axillary artery dissection, and 711 patients did not. Direct right axillary artery cannulation was used for cardiopulmonary bypass in the majority of patients, but with a lower rate in patients with right axillary artery dissection (n = 88 [71.0%] vs n = 579 [81.4%], P = .007). Right axillary artery cannulation failure (n = 3 [2.4%] vs n = 5 [0.7%], P = .102) and related complications (n = 1 [0.8%] vs n = 6 [0.8%], P = 1.000) were rare in both groups. In-hospital mortality (n = 18 [14.5%] vs n = 59 [8.3%], P = .027) and stroke (n = 14 [11.3%] vs n = 42 [5.9%], P = .027) were significantly higher in the right axillary artery dissection group, but after propensity score matching, in-hospital outcomes were comparable. Right axillary artery dissection was not a risk factor for mortality, stroke, right axillary artery cannulation not performed, or right axillary artery cannulation failure.

CONCLUSIONS

Direct right axillary artery cannulation is feasible for most patients with acute type A aortic dissection with right axillary artery dissection.

Stroke After Acute Type A Dissection Repair Using Right Axillary Cannulation First Approach

BACKGROUND

This study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach.

METHODS

A total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography.

RESULTS

The rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2.

CONCLUSIONS

Most strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels.

Zone 2 arch repair for acute type A dissection: Evolution from arch-first to proximal-first repair

Objective

With growing experience of acute type A aortic dissection repair, Zone 2 arch repair has been advocated. The aim of this study is to compare the outcome between "proximal-first" and "arch-first" Zone 2 repair.

Methods

From January 2015 to March 2023, 45 patients underwent Zone 2 arch repair out of 208 acute type A aortic dissection repairs: arch-first, N = 19, and proximal-first technique, N = 26, since January 2021. Indications were aortic arch or descending tear, complex dissection in neck vessels, cerebral malperfusion, or aneurysm of the aortic arch.

Results

The lowest bladder temperature was higher in the proximal-first technique (24.9 °C vs 19.7 °C, P < .001). Cardiopulmonary bypass (230 vs 177.5 minutes, P < .001), myocardial ischemic (124 vs 91 minutes, P < .001), and lower-body circulatory arrest (87 vs 28 minutes, P < .001) times were shorter in the proximal-first technique. The arch-first group required more packed red blood cells (arch-first, 2 units vs proximal-first, 0 units, P = .048), platelets (arch-first, 4 units vs proximal-first, 2 units, P = .003), and cryoprecipitates (arch-first, 2 units vs proximal-first, 1 unit, P = .024). Operative mortality and major morbidities were higher in the arch-first group (57.9% vs 11.5%, P = .001). One-year survival was comparable (arch-first, 89.5% ± 7.0% vs proximal-first, 92.0% ± 5.5%, P = .739). Distal intervention was successfully performed in 5 patients (endovascular, N = 3, and open repair, N = 2).

Conclusions

Zone 2 arch repair using the proximal-first technique for acute type A aortic dissection repair yields shorter lower-body ischemic time with a warmer core temperature, resulting in shorter cardiopulmonary bypass time, less blood product use, and fewer morbidities when compared with the arch-first technique.

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.

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.

Direct Axillary Artery Cannulation for Aortic Surgery: Lessons From Contemporary Experiences

BACKGROUND

This study seeks to assess the outcomes of direct axillary artery (AX) cannulation for thoracic aortic surgery.

METHODS

From October 2009 to November 2021 direct AX cannulation was planned in 515 patients for thoracic aortic pathology. An important aspect of our technique is that the cannula is not inserted deeper than 3 cm. AX cannulation-related events included shift of cannulation site from the initial site, vascular injury, and iatrogenic dissection.

RESULTS

Half of the patients had acute type A dissection (ATAD). An angled cannula was used in 442 patients and a straight cannula in 73 patients (14.2%) after August 2020. A previously cannulated AX was reused in 36 patients (7.0%). Mortality and stroke rates were 5.4% (ATAD vs non-ATAD: 8.0% vs 2.8%, P = .008) and 2.7% (ATAD vs non-ATAD: 4.6% vs 0.8%, P = .034), respectively. AX cannulation-related events were observed in 2.7% of patients. There was no difference in the vascular injury rate between ATAD and non-ATAD cases (1.6% vs 0.4%, respectively; P = .385), between different cannula types (angled vs straight: 0.9% vs 1.4%, P = 1.00), or between primary and redo AX cannulation cases (0.8% vs 2.8%, respectively; P = .791). On multidetector computed tomography analysis using automated 3-dimensional images, the mean distance from the thoracoacromial artery to the vertebral artery on the right and left sides was 8.70 cm and 8.69 cm, respectively.

CONCLUSIONS

Direct AX cannulation for thoracic aortic repair is safe and carries a low rate of vascular injury, especially in elective cases. Our direct cannulation technique, which includes not inserting a cannula deeper than 3 cm, seems to be safe in not occluding the vertebral artery.