Cannulation strategies in type A aortic dissection: a novel insight narrative review

Central versus peripheral cannulation for acute type A aortic dissection: A meta-analysis of over 14,000 patients

OBJECTIVE

The optimal cannulation strategy for patients with acute type A aortic dissections (ATAAD) is unclear.

METHODS

A systematic search was performed to identify all studies comparing aortic and non-aortic cannulation in patients undergoing ATAAD repair. The primary endpoint was overall survival. The secondary endpoints were operative mortality, postoperative stroke, renal failure, renal replacement therapy, paraplegia, and mesenteric ischemia. Pooled meta-analyses with aggregated and reconstructed time-to-event data were performed.

RESULTS

Twenty-three studies were included (aortic: 3904; non-aortic: 10,719). Ten-year overall survival was 61.1 ​% and 58.4 ​% for aortic and non-aortic cannulation, respectively (HR 1.07; 95 ​% CI 0.92-1.25; p ​= ​0.38). No statistically significant difference was observed for operative mortality (p ​= ​0.10), stroke (p ​= ​0.89), renal failure (p ​= ​0.83), or renal replacement therapy (p ​= ​0.77).

CONCLUSION

Patients undergoing surgery for ATAAD can undergo aortic cannulation with similar outcomes to those who undergo non-aortic cannulation.

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.

Central versus peripheral cannulation for acute type A aortic dissection

OBJECTIVE

This study sought to evaluate the impact of central aortic versus peripheral cannulation on outcomes after acute type A aortic dissection repair.

METHODS

This was an observational study using an institutional database of acute type A aortic dissection repairs from 2007 to 2021. Patients were stratified according to central, subclavian, or femoral cannulation. Kaplan-Meier survival estimation and multivariable Cox regression were performed.

RESULTS

The study population consisted of 577 patients who underwent acute type A aortic dissection repair. Of these, central cannulation was used in 490 patients (84.9%), subclavian cannulation was used in 54 patients (9.4%), and femoral cannulation was used in 33 patients (5.7%). Rates of peripheral vascular disease, aortic insufficiency moderate or greater, and cerebral malperfusion differed significantly among the groups, but baseline characteristics were otherwise comparable (P > .05). Operative mortality was lowest in the central cannulation group (9.8%), but this did not differ significantly among the groups. Kaplan-Meier survival estimates were similar among the groups. On multivariable Cox regression, cannulation strategy was not significantly associated with long-term survival.

CONCLUSIONS

Acute type A aortic dissection repair can be safely performed through central aortic cannulation, with outcomes comparable to those obtained with subclavian or femoral cannulation.

Cannulation Strategies in Type A Aortic Dissection: Overlooked Details and Novel Approaches

Aortic dissection type A is a life-threatening condition that frequently necessitates surgical intervention. This review focuses on central aortic cannulation, arch branch vessel (ABV) cannulation, and proximal arch cannulation as key techniques during aortic surgery. It discusses innovative solutions for addressing these challenges. The review synthesizes findings from recent studies and emphasizes the significance of meticulous planning and execution of cannulation in aortic dissection repair. This review aims to contribute to the advancement of surgical practices and the enhancement of patient outcomes in the management of type A aortic dissection (AAD) by addressing these frequently overlooked details.

Cerebral Perfusion and Neuromonitoring during Complex Aortic Arch Surgery: A Narrative Review

Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed.

Clinical Application of Proximal Arch Cannulation in the Surgical Treatment of Acute Type I Aortic Dissection

Objective The goal is to determine the best location for inserting a catheter into the aortic arch of patients with a certain type of aortic dissection (DeBakey type I) by analyzing images of the patient's aortic arch before surgery. This analysis will take into account the shape and structure of the patient's aortic arch to find the most optimal location for cannulation. Methods A retrospective analysis was conducted on 100 patients with acute DeBakey type I aortic dissection diagnosed between January 2021 and February 2023, utilizing the Carestream medical imaging software Image Suite V4 (New York, USA). The study included 67 cases that underwent surgery and 33 cases that did not. The study aimed to evaluate the optimal intubation position on the patient's aortic arch by analyzing the true and false lumen classification, true and false lumen area, and hematoma thickness on the patient's aortic arch, as observed in the aortic computed tomography angiography (CTA) conducted upon admission. Results The vascular axis analysis showed a significant difference in the true lumen area among the three regions that were examined (P < 0.001). Zone 1 had a larger true lumen area of 6.40 ± 2.71 cm² compared to zone 2 with 5.75 ± 2.13 cm² and zone 3 with 4.85 ± 1.70 cm², as determined by statistical analysis. In addition, the statistical analysis of hematoma thickness in the three regions where cannulation can be performed revealed a significant difference among the three groups (P = 0.027). Further analysis showed that there was no significant difference between zone 1 and zone 2 (P = 1.000), a significant difference between zone 1 and zone 3 (P < 0.046), and no significant difference between zone 2 and zone 3 (P = 0.080). The difference between zone 1 false lumen thickness of 1.55 ± 0.51 cm and zone 3 false lumen thickness of 1.33 ± 0.55 cm was found to be small. Conclusion Cannulation of the aortic arch is a common strategy used in cardiac surgery. Accurate cannulation is critical to the success of the procedure. The use of CTA provides valuable guidance for the cannulation procedure. A thorough examination of CTA and precise measurement of relevant parameters can help guide the surgeon to determine the optimal cannulation site. The study found that zone 1 of the aortic arch has the largest area and is the most suitable for cannulation, in accordance with the physiological characteristics and surgical practices of a surgeon. Furthermore, cannulation of the aortic arch has been found to be a safe and effective strategy for cannulation. Overall, careful examination of CTA and accurate measurement of relevant parameters can have a significant guiding effect on the cannulation of the aortic arch, which can lead to improved outcomes in cardiac surgery.

Fluid-structure interaction simulation of visceral perfusion and impact of different cannulation methods on aortic dissection

Hemodynamics in aortic dissection (AD) is closely associated with the risk of aortic aneurysm, rupture, and malperfusion. Altered blood flow in patients with AD can lead to severe complications such as visceral malperfusion. In this study, we aimed to investigate the effect of cannulation flow on hemodynamics in AD using a fluid-structure interaction simulation. We developed a specific-idealized AD model that included an intimal tear in the descending thoracic aorta, a re-entry tear in the left iliac artery, and nine branches. Two different cannulation methods were tested: (1) axillary cannulation (AC) only through the brachiocephalic trunk and (2) combined axillary and femoral cannulation (AFC) through the brachiocephalic trunk and the right common iliac artery. AC was found to result in the development of a pressure difference between the true lumen and false lumen, owing to the difference in the flow rate through each lumen. This pressure difference collapsed the true lumen, disturbing blood flow to the celiac and superior mesenteric arteries. However, in AFC, the pressure levels between the two lumens were similar, and no collapse occurred. Moreover, the visceral flow was higher than that in AC. Lastly, the stiffness of the intimal flap affected the true lumen's collapse.

Left axillary cannulation for acute type A aortic dissection

The most commonly used arterial cannulation sites for type A aortic dissection are right axillary artery, femoral artery and both. Direct central aortic cannulation has also been reported. In rare cases, it is extremely difficult to choose an arterial cannulation site for type A aortic dissection due to involvement of the right axillary and both femoral arteries. Herein, we present a 39-year-old male with acute type A aortic dissection with involvement of the right axillary and both femoral arteries. Left axillary cannulation was made and selective cerebral perfusion was performed through direct left common carotid artery cannulation during circulatory arrest. Surgery was performed to replace the ascending aorta and total arch combined with a frozen elephant trunk implantation. The patient recovered uneventfully. To our knowledge, this is a rare case of total aortic arch replacement with frozen elephant trunk implantation through left axillary arterial cannulation for type A aortic dissection in the literature. Left axillary cannulation is a safe and useful choice for type A aortic dissection surgery when right axillary and femoral cannulation are not safe and reliable.

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.