Cannulation of innominate artery as an alternative to axillary artery in repair for type A aortic dissection

Clinical Efficacy of Hybrid Surgery for Stanford Type A Aortic Dissection

INTRODUCTION

To evaluate the clinical efficacy of hybrid surgery for Stanford type A aortic dissection.

METHODS

Twenty-two patients with Stanford type A aortic dissection were selected. All patients had completed or undergone hybrid surgery, including extracorporeal circulation, treatment of proximal anastomosis of ascending aorta and the distal anastomosis of the ascending aorta, management of the branch vessels on the arch, aortic endovascular repair. This study analyzed the time of surgery and awake, blood transfusion during surgery, patient's drainage, complications and CTA of aorta was re-examined about one month after operation during patients follow-up.

RESULTS

All patients underwent the operation successfully. One patient died of renal failure after the operation. Two patients experienced postoperative neurological complications (anxiety and delirium). Renal function was abnormal in two patients, and one patient needed bedside blood filtration. The serum creatinine levels temporarily increased in seven patients. No stent migration was found during patient follow-up. There was no shift in the stents. The near end of the interlayer was well sealed, without leakage of contrast agent, and the false lumen near the stent was completely thrombosed. Compared with the pre-operative CTA, the true lumen was enlarged and the false lumen was reduced, and the false lumen was completely thrombosed in the proximal end and near the stent. Contrast media was seen in the false lumen.

CONCLUSION

One-stage hybrid surgery for Stanford type A aortic dissection can avoid deep hypothermic circulatory arrest, shorten operation time, reduce operation trauma, and reduce the incidence of postoperative complications. This treatment has a effective treatment effect in the short term. However, the limitations imposed by covered stent materials mean that the treatment's long-term effect is not yet clear, and further research is needed.

In thoracic aortic surgery, is innominate artery cannulation a safe and effective alternative to axillary artery cannulation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in a patient undergoing thoracic aortic surgery, is innominate artery cannulation superior to axillary artery cannulation in terms of postoperative outcomes? Five hundred and thirty-one papers were found using the reported search strategy, of which 5 represented the best evidence to answer the clinical question. A total of 1338 participants were included across the 5 studies. Seven hundred and twenty-two patients were cannulated via the axillary artery and 616 were cannulated via the innominate artery. The included 5 studies were 2 prospective observational cohorts, 2 retrospective case-series analysis and a single-blinded randomized trial. Thirty-day or in-hospital mortality rates were reported in all 5 studies. There were no significant differences in mortality with innominate artery cannulation compared to axillary artery cannulation (P > 0.05), with slightly lower mortality rates in 2 studies, slightly higher mortality rates in 2 and equal in 1 study. Though statistical significance was not demonstrated (P > 0.05), a stroke occurred slightly less frequently in patients receiving innominate artery cannulation compared to axillary artery cannulation in 3 of the 4 studies. Innominate artery cannulation is non-inferior to axillary artery cannulation for thoracic aortic surgery, with a similar level of neuroprotection and is not associated with increased levels of mortality.

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.

Proximal arterial cannulation in thoracic aortic surgery-Literature review

Surgery on thoracic aorta is complex with a number of approaches being required depending on the pathology and anatomy that is specific to each patient and therefore, careful planning is required to ensure successful outcomes. Among the key factors that determine a satisfactory and safe operation is the choice of arterial cannulation site to establish cardiopulmonary bypass and deliver brain protection adequately. Direct proximal aortic cannulation is the gold-standard method for elective aortic root surgery and traditionally femoral arterial cannulation has been used in complex aortic surgeries such as redo or acute pathologies; however, axillary and innominate artery (IA) cannulation has evolved dramatically and several centers are currently using proximal cannulation sites as the default cannulation choice in elective and emergency settings of complex thoracic aortic surgeries. The evidence behind cannulating the IA is growing; however, it is yet to be well established through large studies or trial to confirm its superiority to other methods of central cannulation techniques.

Innominate artery cannulation in aortic surgery: A systematic review

OBJECTIVE

The innominate artery is considered an alternative site for establishing cardiopulmonary bypass in surgical procedures involving the thoracic aorta. This systematic review examines the use of innominate artery cannulation in aortic surgery.

METHODS

A systematic literature search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all studies that utilized innominate artery cannulation for establishing cardiopulmonary bypass and providing cerebral perfusion in thoracic aortic surgery. The data were reviewed up to September 2018.

RESULTS

Acute type A aortic dissection contributed to 36% (n = 818) of the total 2,290 patients. 31.5% (n = 719) underwent surgery on the aortic root only; 54.5% (n = 1246) had ascending and hemi-arch replacement, while 11.5% had total aortic arch replacement and 2.5% had a frozen elephant trunk inserted. Postoperative stroke rate was 1.25% (n = 28), temporary neurological deficit was 4.8% (n = 111). All-cause 30-day mortality rate was 2.7% (n = 61).

CONCLUSION

Innominate artery cannulation is a safe technique in patients who undergo thoracic aortic surgery. It can be utilized, in selected cases, as a reliable route for establishing cardiopulmonary bypass and maintaining cerebral perfusion.