Technical problems and complications of axillary artery cannulation

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.

Development and assessment of novel assist device for cardiac cannulation

PURPOSE

Congenital heart defects are the most common birth defects in the USA and in 25% of cases need to be treated with cardiovascular interventions. One of such interventions is the postoperative use of an extracorporeal membrane oxygenation (ECMO) machine for the treatment of cardiorespiratory failure. The process of placing the patient on the ECMO is extremely time-critical and requires the use of cardiac cannulation. For the first time, our team developed and evaluated a new quick-connect cannulation system that allows for rapid, easy, and safe ECMO cannulation in the pediatric population. The design should eliminate the need for purse-string sutures that are currently used to secure cannulas, as the cannulas will be inserted through a port that is glued to the cardiovascular tissue.

METHODS

The rapid cannulation assistance device was designed on the SolidWorks computer-aided design software using the dimensions of the commercially available arterial and venous catheters. These designs were then 3D printed, and tensile testing was performed. Then, a flow loop was developed, and cannulation was performed and analyzed on both 3D-printed hearts and porcine hearts.

RESULTS

The rapid cannulation assistance device was designed and 3D printed. Tensile testing found that the parts were strong enough to withstand forces that may be introduced in studies. 3D-printed and porcine heart tests with a flow loop found no leakage with the 3D-printed hearts but minimal leaking with the porcine hearts. However, this leakage was observed at the junction between the device and the heart, leading us to believe that a glue better suited to attach the device to the heart would prevent leakage in the future.

CONCLUSIONS

This project successfully demonstrated how a rapid cannulation assistance device could be developed and tested. Future studies will be conducted that address device adhesion to the cardiovascular tissue so that accurate pressure and flow rates can be measured. Future studies will also include testing the device in a fluid environment to more effectively analyze the device success and comparing the time required to cannulate using our device compared to the standard of care.

Direct Aortic Versus Supra-Aortic Arterial Cannulation During Surgery for Acute Type A Aortic Dissection

AIMS

In this study we evaluated the impact of direct aortic cannulation versus innominate/subclavian/axillary artery cannulation on the outcome after surgery for type A aortic dissection.

METHODS

The outcomes of patients included in a multicenter European registry (ERTAAD) who underwent surgery for acute type A aortic dissection with direct aortic cannulation versus those with innominate/subclavian/axillary artery cannulation, i.e. supra-aortic arterial cannulation, were compared using propensity score matched analysis.

RESULTS

Out of 3902 consecutive patients included in the registry, 2478 (63.5%) patients were eligible for this analysis. Direct aortic cannulation was performed in 627 (25.3%) patients, while supra-aortic arterial cannulation in 1851 (74.7%) patients. Propensity score matching yielded 614 pairs of patients. Among them, patients who underwent surgery for TAAD with direct aortic cannulation had significantly decreased in-hospital mortality (12.7% vs. 18.1%, p = 0.009) compared to those who had supra-aortic arterial cannulation. Furthermore, direct aortic cannulation was associated with decreased postoperative rates of paraparesis/paraplegia (2.0 vs. 6.0%, p < 0.0001), mesenteric ischemia (1.8 vs. 5.1%, p = 0.002), sepsis (7.0 vs. 14.2%, p < 0.0001), heart failure (11.2 vs. 15.2%, p = 0.043), and major lower limb amputation (0 vs. 1.0%, p = 0.031). Direct aortic cannulation showed a trend toward decreased risk of postoperative dialysis (10.1 vs. 13.7%, p = 0.051).

CONCLUSIONS

This multicenter cohort study showed that direct aortic cannulation compared to supra-aortic arterial cannulation is associated with a significant reduction of the risk of in-hospital mortality after surgery for acute type A aortic dissection.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04831073.

Midterm Follow-up of the Transatrial-to-Left Ventricle Cannulation for Acute Type A Dissection

BACKGROUND

It is still controversial as to which cannulation strategy for acute type A aortic dissection (AAD) is optimal. Antegrade perfusion to diminish further organ malperfusion and ischemia is preferable.

METHODS

We retrospectively analyzed a total of 420 patients who underwent AAD surgery from January 2001 to December 2020. Group A included 229 patients with a transatrial cannulation; group B included 191 patients with all other additionally used cannulation sites. A retrospective analysis was conducted at 30 days and according to clinical outcome and midterm mortality. Risk factors for probability of death were analyzed by multifactorial logistic regression.

RESULTS

The calculated risk scores and demographic preoperative variables were comparable except for hyperlipoproteinemia (P = .011) and redo operation in group B (P < .001) and more pericardial tamponade in group A (P = .006). In addition, fewer patients with postoperative new onset of renal failure were observed in group A (P = .039), although new onset of dialysis was not different between the groups (P = .878). Patients in group A were discharged from the hospital significantly earlier (P = .004). Nevertheless, although significantly more total arch surgery was performed in group A, shorter operation times (P < .001) and lower transfusion rates were observed in group A. Patients' follow-up after a median time of 3.6 (0.6-7.6) years showed no difference in 30-day, 1-year, and long-term mortality. Multivariate logistic regression revealed aortic valve stenosis (P = .041), coronary artery bypass graft surgical procedures (P = .014), preoperative cardiopulmonary resuscitation (P < .001), and length of surgery (P = .032) as the strongest risk factors for mortality.

CONCLUSIONS

Transatrial cannulation for AAD operation was safe and successfully performed under emergent conditions. Although no benefit in mortality was achieved, clinical benefits of shorter operation times, less transfusion, better kidney preservation, and earlier discharge of the patient were observed.

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.

Evaluation of Different Cannulation Strategies for Aortic Arch Surgery Using a Cardiovascular Numerical Simulator

Aortic disease has a significant impact on quality of life. The involvement of the aortic arch requires the preservation of blood supply to the brain during surgery. Deep hypothermic circulatory arrest is an established technique for this purpose, although neurological injury remains high. Additional techniques have been used to reduce risk, although controversy still remains. A three-way cannulation approach, including both carotid arteries and the femoral artery or the ascending aorta, has been used successfully for aortic arch replacement and redo procedures. We developed circuits of the circulation to simulate blood flow during this type of cannulation set up. The CARDIOSIM© cardiovascular simulation platform was used to analyse the effect on haemodynamic and energetic parameters and the benefit derived in terms of organ perfusion pressure and flow. Our simulation approach based on lumped-parameter modelling, pressure-volume analysis and modified time-varying elastance provides a theoretical background to a three-way cannulation strategy for aortic arch surgery with correlation to the observed clinical practice.

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.

Innominate artery direct cannulation provides brain protection during total arch replacement for acute type A aortic dissection

Background

This study aimed to investigate the safety of direct innominate arterial (IA) cannulation using a pediatric arterial cannula to establish selective antegrade cerebral perfusion (ACP) during total arch replacement (TAR) for acute Stanford type A aortic dissection (ATAAD).

Methods

This retrospective study included patients with ATAAD who underwent TAR with the frozen elephant trunk (FET) technique between October 2020 and November 2021. Patients treated with direct IA cannulation using a pediatric arterial cannula for selective anterograde cerebral perfusion were included in the study.

Results

Of the 29 patients, 24 (82.8%) were male. The average age was 50.9 ± 9.47 years. Proximal repair included aortic root plasty (27 patients, [93.1%]) and Bentall surgery (2 patients, [6.9%]). Perioperative mortality and stroke rates were 3.4% and 6.9%, respectively. The mean lowest core temperature was 23.8 ± 0.74 °C and the mean ACP time was 25 ± 6.4 min. The aortic cross-clamp and cardiopulmonary bypass times were 141 ± 28 and 202 ± 29 min, respectively. There were no cases of IA injuries.

Conclusion

Direct IA cannulation using a pediatric arterial cannula is a simple, safe, and effective technique for establishing ACP during TAR with the FET technique for ATAAD and can avoid the potential complications of axillary artery cannulation.

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.

Direct Innominate Artery Cannulation versus Side Graft for Selective Antegrade Cerebral Perfusion during Aortic Hemiarch Replacement

Background  Selective antegrade cerebral perfusion (SACP) has become our preferred method for cerebral protection during open arch cases. While the initial approach involved sewing a graft to the innominate artery as the arterial cannulation site, our access strategy has since evolved to central aortic cannulation with use of a percutaneous cannula in the innominate for SACP. We hypothesized that SACP delivered via direct innominate cannulation using a 12- or 14-Fr cannula results in equivalent outcomes to cases utilizing a side graft.

Methods  This was a single-center, retrospective analysis of 211 adult patients who underwent elective hemiarch replacement using hypothermic circulatory arrest with SACP via the innominate artery between 2012 and 2020. Urgent and emergent cases were excluded.

Results  A side graft sutured to the innominate was utilized in 81% ( n  = 171) of patients, while direct innominate artery cannulation was performed in 19% ( n  = 40) of patients. Baseline patient characteristics were similar between groups aside from a higher baseline creatinine in the direct cannulation group (1.3 vs. 0.9, p  = 0.032). Patients undergoing direct cannulation demonstrated shorter cardiopulmonary bypass time (132.7 vs. 154.9 minutes, p  = 0.020) and shorter circulatory arrest time (8.1 vs. 10.9 minutes, p  = 0.004). Nadir bladder temperature did not significantly differ between groups (27.2°C for side graft vs. 27.6°C for direct cannulation, p  = 0.088). There were no significant differences in postoperative outcomes.

Conclusion  Direct cannulation of the innominate artery with a 12- or 14-Fr cannula for SACP during hemiarch replacement is a safe alternative to using a sutured side graft. While cardiopulmonary bypass and circulatory arrest times appear improved, this is likely attributable to accumulation of experience and proficiency in technique. However, direct innominate artery cannulation may facilitate quicker completion of these procedures by eliminating the time necessary to suture a graft to the innominate artery.

Neuroprotective strategies with circulatory arrest in open aortic surgery - A meta-analysis

Objective

Deep hypothermic circulatory arrest (DHCA) in aortic surgery is associated with morbidity and mortality despite evolving strategies. With the advent of antegrade cerebral perfusion (ACP), moderate hypothermic circulatory arrest (MHCA) was reported to have better outcomes than DHCA. There is no standardised guideline or consensus regarding the hypothermic strategies to be employed in open aortic surgery. Meta-analysis was performed comparing DHCA with MHCA + ACP in patients having aortic surgery.

Methods

A systematic review of the literature was undertaken. Any studies with DHCA versus MHCA + ACP in aortic surgeries were selected according to specific inclusion criteria and analysed to generate summative data. Statistical analysis was performed using STATS Direct. The primary outcomes were hospital mortality and post-operative stroke. Secondary outcomes were cardiopulmonary bypass time (CPB), post-operative blood transfusion, length of ICU stay, respiratory complications, renal failure and length of hospital stay. Subgroup analysis of primary outcomes for Arch surgery alone was also performed.

Results

Fifteen studies were included with a total of 5869 patients. There was significantly reduced mortality (Pooled OR = +0.64, 95% CI = +0.49 to +0.83; p = 0.0006) and stroke rate (Pooled OR = +0.62, 95% CI = +0.49 to +0.79; p < 0.001) in the MHCA group. MHCA was associated significantly with shorter CPB times, shorter duration in ICU, less pulmonary complications, and reduced rates of sepsis. There was no statistical difference between the two groups in terms of circulatory arrest times, X-Clamp times, total operation duration, transfusion requirements, renal failure and post-op hospital stay.

Conclusion

MHCA + ACP are associated with significantly better post-operative outcomes compared with DHCA for both mortality and stroke and majority of the secondary outcomes.

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.

Direct proximal right subclavian artery cannulation during surgery of the thoracic aorta

OBJECTIVE

To evaluate outcomes of single sternum access for right subclavian artery cannulation without infraclavicular incision in surgery of the thoracic aorta.

METHODS

Between January 2015 and December 2019, 44 consecutive patients underwent surgery of the thoracic aorta with cannulation of the right subclavian artery, after sternotomy and before pericardiotomy, through a direct percutaneous cannula with a single access without additional infraclavicular skin incision. The indication for surgery was type A acute aortic dissection in 29 patients (65.9%), proximal aortic aneurysm in 11 (25%), and aneurysm of the aortic arch in 4 (9%). Operative procedures were replacement of the ascending aorta in 23 patients, Bentall procedure in 10, hemiarch replacement in 6, and total arch replacement in 5. The mean cardiopulmonary bypass (CPB) and cross-clamp times were 185 ± 62 minutes and 138 ± 41 minutes, respectively.

RESULTS

The in-hospital mortality rate was 6.8%. Permanent neurologic dysfunction occurred in 3 patients (6.8%) and temporary neurologic dysfunction occurred in 4 patients (9.0%). There were no vascular complications related to this technique. No lesions to the vagus and recurrent laryngeal nerves have been reported.

CONCLUSIONS

In our experience, a single sternum access for right subclavian artery cannulation avoids the risk and complications of an infraclavicular incision required for axillary artery cannulation. This technique is safe and represent a valid option for CBP and antegrade cerebral perfusion during surgery of the thoracic aorta.

Alternative Approach for Cerebral Protection during Complex Aortic Arch and Redo Surgery

Total arch replacement remains a very demanding surgical procedure. It can be associated with reasonable long-term outcomes but carries serious perioperative complications. Aortic arch surgery has progressed in recent years to a wider adoption of reproducible and reliable techniques. Conventional open, surgical aortic arch replacement is currently offered to the majority of patients, although hybrid and wholly endovascular techniques are gaining popularity. With regards to open arch replacement, the nuances of surgical technique, the mode of cannulation and the optimal cerebral protection protocols remain a matter of debate. We propose an alternative cannulation approach facilitated by the cooperation between cardiac and vascular surgeons. A three-way arterial cannulation including both carotid arteries and the femoral artery (or ascending aorta) is the key feature of this approach. A case series of complex patients is presented to show both the feasibility and relative safety of a standardised new approach with a 100% technical success rate and a 16% 30-day mortality. The three-way cannulation approach may have a role to play for complex and extensive procedures requiring prolonged cerebral protection. We believe that a shared skill set from cardiac and vascular specialists is essential for the safe management and successful outcomes using this adaptive technique.

Femoral versus axillary cannulation in acute type A aortic dissections: A meta-analysis

OBJECTIVE

There has been a growing interest in antegrade cannulation techniques in type A aortic dissection surgery. Axillary cannulation has previously been reported to provide better outcomes in terms of short-term mortality and neurological event. Consensus regarding the best cannulation strategy still remains controversial.

METHOD

The MEDLINE and EMBASE databases were conducted up until October 3, 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random-effects modelling and the I² -test for heterogeneity. Fourteen retrospective observational studies were included, enrolling a total of 2621 patients.

RESULTS

There were a total of 2621 patients (1327 axillary cannulation and 874 femoral cannulation). Axillary cannulation was associated with reduced short term mortality (pooled odds ratio [OR] = +0.42, 95% confidence interval [CI] = +0.25 to +0.70; p = .0009) compared to femoral cannulation. Axillary cannulation was also associated with a lower incidence of neurological events (pooled OR = +0.63, 95% CI = +0.42 to +0.94; p = .02).

CONCLUSION

Our meta-analyses suggests that axillary cannulation has superior outcomes in terms of mortality and stroke following emergency surgery for type A aortic dissection. However, the lack of high quality randomized controlled trials does not make this recommendation generalisable to all units.

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.

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

BACKGROUND

This study seeks to assess the safety of direct axillary artery (AX) cannulation for acute type A dissection (ATAD) repair, including the impact of innominate artery dissection (IAD).

METHODS

Of 281 consecutive patients who underwent ATAD repair from 2007 to 2020, preoperative computed tomography was available in 200 (IAD: N=101, non-IAD N=99). IAD with compromised true lumen was defined as dissection in which the false lumen was greater than 50% of the IA diameter (N=75/101).

RESULTS

AX cannulation was attempted in 188 patients (94.0%), with a 1.6% vascular injury rate (3 patients; bypass to the distal AX: 2 patients, and local dissection: 1 patient). Most patients (89.5%) underwent hemiarch replacement using deep hypothermic circulatory arrest for the distal repair. Right AX cannulation was used in 80.2% of patients with IAD and in 88.9% without IAD (p=0.075). Patients with IAD had more cerebral (21.8%vs. 5.1%, p=0.001) and arm malperfsion (11.9% vs.4.0%, p=0.075). Operative mortality and stroke were comparable between Non-IAD and IAD groups (8.1% vs. 7.9%, p=1.00 and 4.0% vs. 5.3%, p=0.689). The right AX was successfully used in 77.3% of IAD patients having a compromised true lumen, with comparable hospital outcomes to non-compromised IAD patients. Upper extremity malperfusion, multi-organ malperfusion, low ejection fraction, and female gender were predictors for non-right AX cannulation.

CONCLUSIONS

Routine direct AX cannulation strategy is safe in ATAD repair. Right AX cannulation can be used in most patients with IAD, even with a compromised true lumen, with low mortality, stroke and vascular injury rates.

Computational numerical analysis of different cannulation methods during cardiopulmonary bypass of type A aortic dissection model based on computational fluid dynamics

Background

The aim of the present study was to use a numerical simulation based on computational fluid dynamics (CFD) to analyze the difference of different cannulation methods on hemodynamics characteristic in a type A aortic dissection (TAAD) model.

Methods

A finite-element analysis based on the CFD model of a TAAD patient was used, and axillary artery cannulation (AAC), innominate artery cannulation (IAC), and femoral artery cannulation (FAC) were analyzed under different situations, including a cardiac output (CO) of 2.5 L/min and cardiopulmonary bypass (CPB) of 2.5 L/min (partial CPB before cross-clamping aorta, defined as condition A), and a CO of 0 L/min and CPB of 5 L/min (aortic cross-clamping phase, defined as condition B). The insertion of an 8-mm cannula into the different models was simulated. Hemodynamic characteristics, including wall shear stress, wall stress, blood flow, and velocity were analyzed.

Results

In condition A, the total flow of branches of the aortic arch was 2,009.5 mL/min (AAC), 1,855.47 mL/min (IAC), and 1,648.03 mL/min (FAC). All cannulation methods improved left renal blood perfusion. However, in relation to blood flow in the right renal artery, FAC showed the highest blood flow (105 mL/min). The results in condition B were similar to those of condition A. The velocity, shear stress, and stress of entry tear via AAC and IAC decreased in condition B compared with condition A. The velocity, shear stress, stress of tear via AAC was lower than that of IAC.

Conclusions

Different cannulation modes have an effect on the hemodynamic characteristic of the tear, but this effect is related to different states of CPB. AAC was found to superior to IAC, especially in reducing velocity, stress, and shear stress of site of tear. However, IAC and AAC are more conductive to blood supply than FAC in branch vessels of the aortic arch without being affected by the CPB state.

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation

BACKGROUND

To evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).

METHODS

Between January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.

RESULTS

After propensity score matching, the patients' characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.

CONCLUSIONS

Femoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.

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.

Direct true lumen cannulation in type A acute aortic dissection: A review of an 11 years' experience

Objectives

Direct true lumen cannulation (DTLC) of the aorta is an alternative cardiopulmonary bypass cannulation technique in the context of type A acute aortic dissection (A-AAD). DTLC has been reported to be effective in restoring adequate perfusion to jeopardized organs. This study reports and compares operative outcomes with DTLC or alternative cannulation techniques in a large cohort of patients with A-AAD.

Methods

All patients who underwent surgery for A-AAD between January 2006 and January 2017 in Mainz university hospital were reviewed. The choice of cannulation technique was left to the operating surgeon, however DTLC was our preference in patients who were in state of shock or showed signs of tamponade or hypoperfusion, in cases of potential cerebral malperfusion, as well as in patients who were under resuscitation.

Results

A total of 528 patients (63% males, mean age 64±13.8 years) underwent emergency surgery for A-AAD. The DTLC technique was used in 52.4% of patients. The DTLC group of patients had worse clinical status at the time of presentation with more shock, tamponade, true lumen collapse, cerebral and other malperfusion states. New neurologic events were diagnosed in around 8% of patients in each group following surgery, but there was a trend for quicker neurological recovery in the DTLC-group. Early mortality rates, short-term and long-term survival rates did not differ between the two groups.

Conclusions

DTLC is a safe cannulation technique that enables effective antegrade true lumen perfusion in complicated A-AAD scenarios, and is an advantageous addition to the aortic surgeons’ armamentarium.

Iatrogenic Aortic Dissection Associated With Cardiac Surgery: A Narrative Review

Iatrogenic aortic dissection (iAD) is a relatively rare but a life-threatening complication associated with cardiac surgery. All members of the team caring for cardiac surgical patients (surgeons, perfusionists, and anesthesiologists) must be familiar with this complication to minimize its incidence and improve outcome. The present narrative review focuses on iAD occurring intraoperatively and during the early postoperative period (within 1 month) of cardiac surgery. The review also addresses iAD that occurs late (beyond 1 month) after cardiac surgery and iAD associated with other procedures. iAD occurs in about 0.06% of cases when the ascending aorta is the site of arterial cannulation, in about 0.6% when the femoral or iliac arteries are used, and in about 0.5% when the axillary or subclavian arteries are used. Mortality is estimated to be 30% but is more than double if not recognized until the postoperative period. Site of origin of dissection is most commonly the arterial inflow cannula (∼33%). Other common sites are the aortic cross-clamp or partial occlusion clamp (∼29%) and the proximal saphenous vein anastomosis site (14%). Sixty percent of cases occur during coronary artery bypass graft (CABG) surgery and 17% during aortic valve surgery with or without CABG. iAD may be somewhat less common in off-pump versus on-pump CABG but is still not very rare. Risk factors, presentation, diagnosis, and management are reviewed in detail as is the key role of the use of echocardiography in the early diagnosis of iAD and for guiding its management.

The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection

BACKGROUND

Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection.

METHODS

A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis.

RESULTS

Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%).

CONCLUSIONS

This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

Upper-body cannulation for midterm mechanical circulatory support: A novel bridging strategy to cardiac retransplantation

Heart retransplantation remains a controversial issue, due to the overall shortage of donor organs. Many patients put on the waiting list for retransplantation, decompensate rapidly, and do not survive. The use of veno-arterial extracorporeal life support remains an option in such emergency situations as bridge-to-recovery or bridge-to-transplantation therapy. In peripheral femoral configuration, veno-arterial extracorporeal life support improves the patient's condition by relieving low-cardiac output but immobilizes him or her for an uncertain period of time. The upper-body cannulation is an alternative approach, which allows to maintain the patient awake and mobile. We present two cases of midterm circulatory support as a bridge to heart retransplantation, using upper-body cannulation veno-arterial extracorporeal life support. Two male patients, presenting with progressive cardiac decompensation due to severe graft rejection, were placed on upper-body veno-arterial extracorporeal life support. The stabilization of hemodynamics and improvement of end-organ perfusion could be achieved after extracorporeal life support initiation. After 48 and 40 days, respectively, on extracorporeal life support with active physical therapy and no major adverse events, both patients received a cardiac retransplantation and were eventually discharged home. The presented cases are the first reported where a successful cardiac retransplant was performed following prolonged upper-body extracorporeal life support.

A simple method to establish antegrade cerebral perfusion during hemiarch reconstruction

Objective

We describe a novel and safe technique using a 12F-14F pediatric arterial cannula to establish unilateral, selective, antegrade cerebral perfusion (ACP) during open hemiarch reconstruction.

Methods

Between January 2015 and September 2018, 42 patients underwent elective aortic aneurysm repair requiring an open distal anastomosis and at least a hemiarch replacement via hypothermic circulatory arrest by 2 surgeons. All distal reconstructions were performed at moderate hypothermia (22°C-26°C) with direct cannulation of the innominate artery (IA) using a pediatric arterial cannula to allow ACP at 10-15 mL/kg/min. Data were collected by retrospective chart review.

Results

Thirty-one of the 42 patients (74%) were male. The mean patient age was 65 ± 13 years, and the mean body surface area was 2.1 ± 0.3 m². Proximal repairs included a modified Bentall with a valve-graft composite (n = 17), valve-sparing root replacement (n = 2), and aortic valve replacement (n = 15). Perioperative mortality was 2% (n = 1), and the incidence of stroke was 0%. The mean lowest core body temperature reached during circulatory arrest was 23.8 ± 2.7°C with a mean ACP time of 21.8 ± 3.6 minutes. The mean aortic cross-clamp and cardiopulmonary bypass times were 160.6 ± 55.5 minutes and 204.7 ± 57.5 minutes, respectively. There were no cases of IA injury.

Conclusions

Direct IA cannulation with a pediatric arterial cannula is a safe and efficient method to allow ACP in aortic surgery requiring hypothermic circulatory arrest and may circumvent the potential complications of axillary cannulation.

Percutaneous or Side-Arm Graft Right Subclavian Artery Cannulation via Median Sternotomy

Several cannulation sites alternative to the ascending aorta, such as femoral, right axillary, carotid, innominate artery, and, less commonly, apical sites, have been proposed. Cannulation of the right subclavian artery, through sternotomy, is one possible means of establishing cardiopulmonary bypass, hence avoiding a second surgical incision. In our experience, cardiopulmonary bypass flow was adequate and circulatory arrest with antegrade cerebral perfusion was successfully performed in all cases. There was no in-hospital mortality.

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.

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.

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.

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.

Dermatologic complication following axillary cannulation for aortic dissection repair

It is important to be aware of complications associated with axillary artery cannulation, especially the more common ones that can compromise limb integrity. Pulse oximeter and arterial line placed on the right upper extremity can aid in perfusion of the right arm during right axillary artery cannulation.

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.

Varying Evidence on Deep Hypothermic Circulatory Arrest in Thoracic Aortic Aneurysm Surgery

Cardiovascular surgeons have long debated the safe duration of deep hypothermic circulatory arrest during thoracic aortic aneurysm surgery. The rationale for using adjunctive cerebral perfusion (or not) is to achieve the best technical aortic repair with the lowest risk of morbidity and death. In this literature review, we highlight the debates surrounding these issues, evaluate the disparate findings on deep hypothermic circulatory arrest durations and temperatures, and consider the usefulness of adjunctive perfusion.

Cerebral Pathophysiology in Extracorporeal Membrane Oxygenation: Pitfalls in Daily Clinical Management

Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that is widely being used in centers throughout the world. However, there is a paucity of literature surrounding the mechanisms affecting cerebral physiology while on ECMO. Studies have shown alterations in cerebral blood flow characteristics and subsequently autoregulation. Furthermore, the mechanical aspects of the ECMO circuit itself may affect cerebral circulation. The nature of these physiological/pathophysiological changes can lead to profound neurological complications. This review aims at describing the changes to normal cerebral autoregulation during ECMO, illustrating the various neuromonitoring tools available to assess markers of cerebral autoregulation, and finally discussing potential neurological complications that are associated with ECMO.

Left Axillary Artery Cannulation Facilitates Reoperative Total Aortic Arch Replacement

Total aortic arch replacement remains a technically formidable procedure, particularly in patients with previous proximal aortic dissection repair. Our case discussion highlights a useful strategy for extracorporeal support and circulation management to facilitate total arch reconstruction in the reoperative setting, based on cannulation of the left axillary artery. Our preference is to use a left axillary artery approach to initiate cardiopulmonary bypass and to ultimately revascularize the left arm via an extra-anatomic graft. Our technique, as described, affords the option to initiate cardiopulmonary bypass before sternal re-entry, it reduces the risk of embolic complications and possible stroke, and it directly facilitates simple extra-anatomic debranching of the left subclavian artery, resulting in easier arch and great vessel reconstruction within the chest.

True Lumen Perfusion Technique for Extensive Aortic Dissections Involving the Neck and Femoral Vessels

Cannulation and perfusion in extensive aortic dissection involving the neck and femoral vessels is challenging in view of false lumen cannulation and attendant malperfusion syndromes. Although a number of methods have been described, our technique of cannulation and perfusion through right atrial-to-left atrial bypass and innominate artery transection ensures adequate brain perfusion and visceral organ true lumen perfusion during the entire duration of cardiopulmonary bypass. This procedure can be applied to all varieties of extensive type A aortic dissections involving the neck and femoral vessels. A step-by-step of how to do it has been described.