Fatal intraoperative dissection of the innominate artery due to perfusion through the right axillary artery

Cannulation strategies in aortic surgery: techniques and decision making

Arterial cannulation for cardiopulmonary bypass (CPB) is an important determinant of outcome in aortic surgery. Unlike traditional cardiac operations, aortic pathology may preclude the cannulation of the distal ascending aorta. In other cases, special need of the pathology/operation may demand an alternative cannulation site. Choosing the right cannulation site, especially in type A aortic dissection, is the most crucial initial step. The decision about cannulation sites should be individualized and patient-specific. Various cannulation techniques include femoral, right axillary, innominate, carotid, central aortic, direct true lumen, transapical, and trans-atrial left ventricle cannulation. The ideal cannulation should be easy, quick, and suitable for all clinical scenarios. It should allow smooth conduct of CPB without malperfusion or cerebral embolization. The cannulation strategy should also provide an option for selective antegrade cerebral perfusion and it should be free from neurovascular and local site complications. There is no ideal cannulation technique. Each technique has its pros and cons. Excellent results and drawbacks have been reported with each technique. Final selection of the cannulation site is dependent upon several factors. However, a surgeon's familiarity with a particular technique plays a major role in selection. Despite this, there is a definite shift in surgeons' preference from femoral to central cannulation (axillary, carotid, innominate, aortic) over the last few decades. The aim of this review is to give a brief overview of the cannulation techniques in aortic surgery and discuss the decision-making process.

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

This review highlights vital details that can be easily overlooked and discuss how to identify and fix failed cannulation from another novel insight. Appropriate arterial cannulation strategy during cardiopulmonary bypass (CPB) in Stanford type A aortic dissection (AAD) is highly necessary to reach satisfactory perfusion effects and appreciable clinical outcomes. Despite several previously published reviews on cannulation strategies in AAD, most focus on the advantages and disadvantages by comparing various cannulation strategies. In fact, most of evidence came from retrospective studies. More importantly, however, some important details and novel approaches maybe overlooked due to variety reasons. These overlooked details also make sense in clinical practice. Papers related to cannulation refer to type AAD were retrieved and analyzed from the PubMed and Medline database. The key words such as “aortic dissection”, “cannula”, “cannulation”, “cannulation strategy”, “cerebral perfusion”, “type I aortic dissection” were conducted and analyzed. In addition, we looked at some new and very significant specific perfusion techniques such as anterograde cerebral perfusion combined with retrograde inferior vena caval perfusion (RIVP) and reperfusion via the right carotid artery before surgery. The arterial cannulation site and strategy should be determined individually. Monitoring measures are very necessary in the whole procedure.

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.

Innominate artery dissection due to selective cerebral antegrade perfusion

We present the first case of successfully treated innominate artery dissection as a complication of selective cerebral antegrade perfusion during reoperative aortic valve and hemiarch replacements. Innominate artery dissection was suspected based on unilateral decreases in the right radial arterial pressure and right cerebral oximetry value. Intraoperative ultrasonography demonstrated minimal flow in the right internal carotid. A right aortoaxillary bypass graft was performed leading to immediate improvements in the right radial arterial pressure waveform and right cerebral oximetry. The patient was discharged neurologically intact on postoperative day six.

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.

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.

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.

Aortic arch cannulation with the guidance of transesophageal echocardiography for Stanford type A aortic dissection

BACKGROUND

Aortic arch cannulation for an antegrade central perfusion during the surgery for Stanford type A aortic dissection can be performed within median sternotomy. We summarize the safety and convenient profile of the central cannulation strategy using the guidance of transesophageal echocardiography (TEE) in comparison to traditional femoral cannulation strategy.

METHODS

Sixty-two patients with acute Stanford type A aortic dissection underwent aortic arch surgery in our hospital. All the patients were operated by the same surgeon. Cannulation was performed in 33 patients through the aortic arch under the guidance of TEE (Group A) and in 29 patients through the femoral artery (Group F). Under moderate hypothermic circulatory arrest, the brain is continuously perfused in an anterograde manner through the brachiocephalic and left common carotid arteries. Preoperative characeristics and surgical information were collected for each patient. Additionally, 30-day mortality rate and the incidence of the temporary neurological dysfunction were recorded as the outcomes. To compare the categorical variables, we used the chi-squared test. Continuous variables were compared using the t-test.

RESULTS

Preoperative characteristics were almost similar between the two groups. The mean operation time (7.33 ± 1.14 h vs. 8.93 ± 2.59 h, P = 0.002) and the mean cardiopulmonary bypass (CPB) time (260.97 ± 45.14 min vs. 298.28 ± 95.89 min, P = 0.024) were significantly shorter in Group A than those in Group F. The 30-day mortality rates were 9.09 and 27.59% in Groups A and F, respectively (P = 0.057). And the incidences of temporary neurological dysfunction were 39.39 and 65.52% in Group A and F, respectively (P = 0.040).

CONCLUSIONS

Aortic arch cannulation with the guidance of TEE during the aortic arch surgery is a simple, fast, safe, and less invasive technique for establishing cardiopulmonary bypass for Stanford type A aortic dissection.

Carotid artery cannulation in aortic surgery

The common carotid artery is not widely used for arterial return in cardiovascular surgery with the use of extracorporeal circulation; however, in our opinion, it is an artery that most ideally fits several criteria for cannulation use. It is easy and very fast to access, even in obese patients, and it is large and strong enough to provide a sufficient arterial return. Moreover, the risk of local injuries and wound infection is extremely low, and finally, the use of the common carotid artery for cannulation is very advantageous for cerebral perfusion in many pathologies of the aortic arch and its branches.

Impact of transapical aortic cannulation for acute type A aortic dissection

OBJECTIVE

Early and mid-term result of transapical aortic (TAA) cannulation technique was evaluated compared with femoral artery (FA) cannulation in Acute Type A Aortic Dissection(AAAD).

METHODS

From January 2000 to October 2013, 80 consecutive patients with AAAD were underwent the ascending aortic replacement at Nagasaki Kouseikai Hospital. These patients were divided into two groups according to the cannulation site, FA cannulation (n = 34) and TAA cannulation (n = 46). Early and mid-term outcomes were compared between two groups.

RESULT

Preoperative patient characteristics were almost comparable between groups. The time from skin incision to starting cardiopulmonary bypass (CPB) was significantly shorter in the TAA group (45 ± 16 vs 23 ± 5.1 min; P <0.001). There were no significant differences in post-operative cerebral infarction in two groups (17% versus 11%; P = NS). The operative mortality rate was 8.8% in FA group and 4.3% in TAA group (P = NS). During follow up (mean, 6.8 years), survival at 3 years and 5 years was 77.4% and 71.9% in TAA group and 76.3% and 73.8% in FA group, respectively.

CONCLUSION

The postoperative morbidity and mortality between the two groups were almost the same. TAA cannulation for acute Type A aortic dissection is faster, easy and safe with acceptable early and mid-term outcome.

Uncertainty of axillary artery perfusion during surgery for acute aortic dissection

We treated a patient with acute aortic dissection, which affected the innominate and carotid arteries. Although the true lumen was adequately wide and cerebral malperfusion deemed unlikely, extracorporeal circulation through the femoral artery caused right cerebral malperfusion, and addition of right axillary artery perfusion was ineffective. Several minutes after innominate artery snaring, cerebral blood flow was suddenly restored and the clinical outcome was favorable. Axillary artery perfusion is occasionally unreliable and inevitably demands careful cerebral flow monitoring. A dead-end false lumen in the innominate and carotid arteries requires special caution. A dual-artery perfusion strategy permits innominate artery occlusion as an emergency measure against unexpected malperfusion.

Innominate truncal and arch blowout with left hemiparesis and right hemothorax followed by delayed cheese-wire perforation of innominate graft

We present the case of a 68 year old Caucasian woman, in extremis, with left hemiparesis and right hemothorax, in hypovolemic shock, secondary to a blow-out of a large penetrating ulcer at the junction of innominate trunk and aortic arch. She underwent interposition graft replacement of innominate trunk and repair of aortic arch, on cardiopulmonary bypass, employing total circulatory arrest and selective antegrade cerebral perfusion and had total resolution of hemiparesis. She, however, represented, 6 months later, with threatened exsanguination after a sternal wire cheese-wired through the sternum and perforated the anteriorly lying innominate graft. Following successful repair, she was found to have an old intramural hematoma of distal arch and descending thoracic aorta and changes suggestive of chronic dissection of the whole of abdominal aorta. This was managed conservatively.

We believe this patient’s presentation initially with a spontaneous innominate blow-out, cardiogenic shock, hemothorax and hemiparesis, and later with cheese-wire perforation of the innominate graft is unique. Her surgical rescue at both presentations was equally unusual, and without surgical precedent to the best of our knowledge. Was the initial innominate blow-out the result of localised innominate dissection, or more unusually, part of retrograde descending thoracic dissection with skip penetration of innominate artery and sparing of the intervening arch? Was it secondary to the minor fall she had sustained 1 week prior to the event, resulting in a false aneurysm or a contained hematoma next to the innominate artery? More intriguingly, did diffuse aortopathy underpin these diverse etiologies and result in penetrating intimal ulcer with blow out in the innominate artery, intramural hematoma in the arch and descending thoracic aorta and dissection in abdominal aorta at different points in time?

We review the current literature for these unusual afflictions of innominate trunk and its origin from the arch of aorta.

Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.

Clinical Results of Ascending Aorta and Aortic Arch Replacement under Moderate Hypothermia with Right Brachial and Femoral Artery Perfusion

Background

Selective antegrade perfusion via axillary artery cannulation along with circulatory arrest under deep hypothermia has became a recent trend for performing surgery on the ascending aorta and aortic arch and when direct aortic cannulation is not feasible. The authors of this study tried using moderate hypothermia with right brachial and femoral artery perfusion to complement the pitfalls of single axillary artery cannulation and deep hypothermia.

Materials and Methods

A retrospective analysis was performed on 36 patients who received ascending aorta or aortic arch replacement between July 2005 and May 2010. The adverse outcomes included operative mortality, permanent neurologic dysfunction and temporary neurologic dysfunction.

Results

Of these 36 patients, 32 (88%) were treated as emergencies. The mean age of the patients was 61.9 years (ranging from 29 to 79 years) and there were 19 males and 17 females. The principal diagnoses for the operation were acute type A aortic dissection (31, 86%) and aneurysmal disease without aortic dissection (5, 14%). The performed operations were ascending aorta replacement (9, 25%), ascending aorta and hemiarch replacement (13, 36%), ascending aorta and total arch replacement (13, 36%) and total arch replacement only (1, 3%). The mean cardiopulmonary bypass time was 209.4±85.1 minutes, and the circulatory arrest with selective antegrade perfusion time was 36.1±24.2 minutes. The lowest core temperature was 24±2.1℃. There were five deaths within 30 post-op days (mortality: 13.8%). Two patients (5.5%) had minor neurologic dysfunction and six patients, including three patients who had preoperative cerebral infarction or unconsciousness, had major neurologic dysfunction (16.6%).

Conclusion

When direct aortic cannulation is not feasible for ascending aorta and aortic arch replacement, the right brachial and femoral artery can be used as arterial perfusion routes with the patient under moderate hypothermia. This technique resulted in acceptable outcomes.

Innominate truncal dissection and rupture into right pleural cavity following acute type A dissection of the aorta with right coronary ostial avulsion and inferior STEMI

An innominate truncal dissection and rupture into the right pleural cavity with massive hemothorax is the initial presentation in this 66-year-old lady with type A dissection of the aorta complicated by right coronary ostial avulsion and inferior STEMI. She underwent supracoronary interposition graft replacement of the ascending aorta and hemiarch, interposition graft replacement of the innominate trunk and saphenous vein bypass grafting of the right coronary artery successfully. Innominate truncal rupture following aortic dissection is practically unknown and has not been described before in the absence of aortic rupture. Innominate truncal rupture secondary to other pathologies presents with supraaortic and mediastinal hematomas, but almost never with right hemothorax. On the backdrop of this unusual presentation with no neurological injury, we review the literature for innominate truncal dissection and rupture, other etiologies for innominate truncal rupture, the complex interplay of factors determining neurological injury and discuss the changes in the strategies and conduct of arterial return during cardiopulmonary bypass and selective antegrade perfusion imposed by this previously undescribed instance of innominate truncal rupture due to dissection.

Comparison of ascending aorta versus femoral artery cannulation for acute aortic dissection type A

BACKGROUND

The site of cannulation for repair of ascending aortic dissection remains controversial. We present our experience with ascending aortic cannulation for acute aortic dissection type A.

METHODS AND RESULTS

From January 1988 to September 2007, we operated on 242 patients for acute aortic dissection type A. Medical records of 235 patients who received ascending aortic cannulation or femoral cannulation were retrospectively reviewed. Long-term follow-up was complete in 97% of patients. Cannulation was accomplished in 82 patients through the ascending aorta and in 153 patients through the femoral artery. Preoperative patient characteristics were almost comparable between groups. Similarly, there were no differences in preoperative patient characteristics and intraoperative parameters including operation time, bypass time, cross-clamp time, hypothermic circulatory arrest time, and percentage of total arch replacement. The 30-day mortality rate was 14% in the aortic group and 23% in the femoral group (P=0.07), and incidence of stroke was 4.9% in the aortic group and 4.5% in the femoral group (P=0.86). During follow-up (mean, 5.5 years), survival at 5 years and 10 years was 65% and 41% in the aortic group and 64% and 46% in the femoral group, respectively (P=0.97).

CONCLUSIONS

The cannulation site should be chosen according to the patient's pathology and status, and the present study suggests that ascending cannulation in patients with acute aortic dissection type A can be a safe alternative, offering acceptable early and long-term outcomes.

[Alternative arterial cannulation site in acute aortic dissections]

INTRODUCTION

Acute aortic dissection is an urgent surgical disease. Often, due to hemodynamic instability, that is an indication for emergent surgical intervention. Majority of surgeons uses Femoral or Axillary artery as arterial inflow site forextracorporal circulation. Both approaches have disadvantages that potentially may cause devastating complications. Some of them have been described in literature such as inadequate flow on heart-lung machine, retrograde dissection and malperfusion syndrome.

AIM OF STUDY

Aim of study is to show, that by using transventricular cannulation we are eliminating all technical problems and lowering peroperative morbidity and mortality.

METHOD

Between 1996-2006 at Institute for Cardiovascular Disease "Dedinje" 107 patients were operated for acute ascending aortic dissection Femoral artery was used for arterial cannulation in 91 patients. Last 16 patients were operated by using transventricular approach to establish extracorporeal circulation. We used retrograde cerebral perfusion in 21 cases at the beginning of our experience.

RESULTS

In group of patients where transapical cannulation was used, no neurological incidents were noticed. We didn't have any other problems related to extracorporeal circulation or placement of arterial cannula. Is this series we had only one death case. Patient passed away on eight postoperative day due to multiorgan insufficiency.

CONCLUSION

Transapical cannulation is very simple and safe method for quick establishment of extracorporeal circulation. It always gives patient sufficient antegrade, physiological flow on heart-lung machine. This is the way to minimize possibility of malperfusion syndrome and to significantly diminish risk of neurological complication. By using this method all negative effects of other cannulation sites will be avoided.

Management of intraoperative malperfusion syndrome using femoral artery cannulation for repair of acute type A aortic dissection

BACKGROUND

The site of cannulation for repair of ascending aortic dissection remains controversial. The objective of this study was to evaluate the incidence and management of intraoperative malperfusion syndrome using femoral cannulation for repair of acute type A aortic dissection.

METHODS

Between May 2002 and February 2007, 107 patients with initial femoral artery cannulation for the repair of type A aortic dissection were enrolled in this study. The mean age was 63.7 +/- 11.8 years; 51 patients were female. Preoperative findings indicated malperfusion in 16 patients. Intraoperative malperfusion syndrome was diagnosed by both radial arterial pressure measurements and transesophageal echocardiography. Clinical outcomes, including specific operative procedures and complications related to the cannulation, were assessed.

RESULTS

The ascending aorta was replaced in 59 patients, hemiarch in 16, and total aortic arch in 32. Intraoperative malperfusion syndrome was noted in 3 patients (lowering of radial pressure in 2, obstruction of the true lumen in 1) at the initiation of cardiopulmonary bypass. After immediately switching to transventricular cannulation, the surgical replacement was successfully performed. The remaining 104 patients underwent surgery during femoral artery bypass without perfusion abnormalities. There was 1 in-hospital death (0.9%), but no deaths among the malperfusion patients. Cerebrovascular deficit occurred in 7 patients (6.5%). One vascular and 3 wound complications occurred related to the femoral cannulation.

CONCLUSIONS

During the repair of acute ascending aortic dissection, malperfusion syndrome related to femoral artery cannulation has an acceptable incidence, and can be managed under appropriate intraoperative monitoring, particularly at the initiation of cardiopulmonary bypass.

Impact of Perfusion Strategy on Neurologic Recovery in Acute Type A Aortic Dissection

BACKGROUND

The optimal perfusion strategy during surgery of acute type A aortic dissection is controversial. The purpose of this study was to determine the impact of retrograde cerebral perfusion during hypothermic circulatory arrest on short-term and long-term outcome in this specific patient population.

METHODS

Between 1984 and 2005, 175 consecutive patients underwent repair of an acute type A dissection. Three different surgical approaches were used: aortic cross-clamping without hypothermic circulatory arrest in 50 (29%), hypothermic circulatory arrest alone in 69 (39%), and hypothermic circulatory arrest with supplemental retrograde cerebral perfusion in 56 (32%).

RESULTS

Operative mortality was 18% +/- 3% (+/- 70% confidence interval), and adverse outcomes (death or cerebrovascular accident) occurred in 21% +/- 3% of patients (p = 0.97 between groups). Multivariate analysis identified valve replacement (p = 0.04), preoperative flow complications (p = 0.03), and non-Marfan syndrome (p = 0.04) as predictors of operative mortality. Intraoperative dissection (p < 0.001) and history of cerebrovascular disease (p = 0.02) were predictors for permanent neurologic deficit, and retrograde cerebral perfusion was shown to have a protective effect on transient neurologic deficits (p = 0.008). Kaplan-Meier survival was 75% +/- 3% at 1 year (131 patients at risk), 63% +/- 4% at 5 years (87 patients at risk), and 49% +/- 4% at 10 years (48 patients at risk) and was independent of surgical approach (p = 0.37). Long-term survival was diminished with increased age (p < 0.001), earlier operative year (p < 0.001), and coronary artery disease (p = 0.02).

CONCLUSIONS

The current investigation suggests improved neurologic recovery with circulatory arrest and supplemental retrograde cerebral perfusion. Operative mortality and long-term survival were comparable among groups.

Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation?

There is a trend towards cannulation of the axillary artery for extracorporeal circulation in patients requiring aortic arch surgery. We analyzed the published data comparing axillary and femoral cannulation for safety and outcome. End points were death; stroke, neurologic, and vascular complications; and malperfusion. Femoral cannulation is safe for extracorporeal circulation in patients without aortic arch surgery. In patients with type A dissections, malperfusion may occur owing to retrograde perfusion of the false lumen and subsequent occlusion of the origin of the supra aortic vessels. Cannulation of the axillary/subclavian artery results in antegrade flow, at least in the right carotid artery, with the possibility of antegrade cerebral perfusion during aortic arch repair. There was a trend towards improved neurologic outcome when the axillary artery was used for extracorporeal circulation in such patients. When different techniques were compared, the use of a side graft for axillary cannulation reduced the complication rate. The lack of randomized trials and the high variety of inclusion criteria in the different studies do not allow a general recommendation for the use of the axillary artery as cannulation site.

Carotid artery cannulation in aortic surgery

OBJECTIVE

Carotid artery cannulation was initially established at our clinic for surgery of acute aortic dissection, and it became the standard approach for procedures in which circulatory arrest is necessary. The aim of the study was to evaluate this method's efficiency regarding postoperative outcomes after the first 100 procedures.

METHODS

Between July 2002 and October 2005, 100 patients underwent aortic surgery using carotid artery cannulation by a side graft for arterial return with a mean flow rate of 4.6 +/- 0.5 L/min. There were 27 patients with acute and 2 with chronic type A aortic dissection. Sixteen patients had had prior cardiac surgery. During circulatory arrest, the arterial line was used for unilateral cerebral perfusion in moderate hypothermia (mean rectal temperature 28 degrees C +/- 1.6 degrees C) with a mean flow rate of 0.85 +/- 0.2 L/min.

RESULTS

Carotid artery cannulation offered adequate arterial return in all patients. In no case was a switch to another cannulation site necessary for arterial return. Furthermore, no complications related to the cannulation site were observed. One patient with acute dissection and 1 with chronic aneurysm died during the early postoperative course. Thus, 30-day mortality was 2.0% for the whole group and 3.7% for the dissection group. Two patients with severe calcification of the aortic valve had strokes. There were no strokes in the dissection group, although there were preoperative signs of cerebral malperfusion in 4 patients.

CONCLUSIONS

Carotid artery cannulation is a fast, safe, and efficient method of arterial cannulation even in very obese patients. In addition, it simplifies the procedure of unilateral cerebral perfusion through the arterial line during circulatory arrest, making it completely unnecessary to interrupt cerebral perfusion.

Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations

OBJECTIVE

The femoral artery is the customary site for arterial cannulation for cardiopulmonary bypass in treating type A aortic dissections. However, because of concerns regarding complications caused by retrograde perfusion, the number of surgeons who prefer using the axillary artery as the site for cannulation is increasing. However, axillary artery cannulation also involves some problems. Thus we prefer transapical aortic cannulation for repair of type A aortic dissection.

METHODS

Transapical aortic cannulation was performed in 138 patients (83 men and 55 women; mean age, 60.1 years; 129 acute and 9 chronic; 120 hemiarch repair and 15 total arch replacement) with type A aortic dissection. A 1-cm incision is made in the apex of the left ventricle, and a 7-mm soft and flexible cannula is passed through the apex and across the aortic valve until positioned in the ascending aorta transesophageal echocardiographic guidance.

RESULTS

There were no cases in which conversion to cannulation of another artery was necessary. In all cases cardiopulmonary bypass flow was sufficient (>2.5 L/m(-2)/min(-1)). There were no malperfusion events. Eight (5.8%) patients had cerebrovascular accidents. Twenty-six (18.8%) patients died in the hospital of complications not related to transapical aortic cannulation.

CONCLUSIONS

Our results show that transapical aortic cannulation is safe and useful for repair of type A aortic dissection. There are advantages to transapical aortic cannulation, such as simple and quick cannulation technique, sufficient antegrade aortic flow, and the reliability of true lumen perfusion with decreased risk of stroke and malperfusion.

Detection and monitoring of complications associated with femoral or axillary arterial cannulation for surgical repair of aortic dissection

OBJECTIVES

Femoral arterial perfusion can be associated with complications, and axillary arterial perfusion is not free from risk. The purpose of this study was to describe the incidence and complications of femoral versus axillary artery cannulation for surgical repair of aortic dissection and to devise a strategy for early detection and monitoring of complications using transesophageal echocardiography, near-infrared spectroscopy, and orbital Doppler.

DESIGN

Retrospective and observational.

SETTING

University hospital.

PARTICIPANTS

Seventy-five consecutive patients with aortic dissection who underwent aortic repair between 1995 and 2004.

INTERVENTIONS

Aortic surgery.

MEASUREMENTS AND MAIN RESULTS

Among the 44 cases with femoral arterial perfusion, sudden onset of hypotension occurred in 3 cases but was immediately treated based on the TEE diagnosis (collapse of true lumen in the descending aorta). In another case, myocardial ischemia occurred because of occlusion of the coronary artery. These four cases comprised 57.1% of 7 patients with type III dissection with retrograde extension in whom femoral arterial perfusion was used. However, malperfusion was not encountered in 3 cases of the same type of dissection but with axillary arterial perfusion. Axillary artery perfusion (29 cases) led to malperfusion of the right frontal lobe and coronary artery in 1 case each.

CONCLUSIONS

Flexible management guided by real-time information is essential. Upon initiating femoral arterial perfusion, malperfusion should first be checked for in the descending aorta and then in the coronary and visceral arteries, especially in cases of type III dissection with retrograde extension. Attention should be paid to cerebral and coronary malperfusion when initiating axillary arterial perfusion.

Isolated cerebral perfusion for intraoperative cerebral malperfusion in type A aortic dissection

Cerebral malperfusion due to expansion of a false lumen can occur acutely during aortic repair when retrograde femoral perfusion is initiated. We detected this catastrophe by a rapid decrease in regional cerebral oxygenation and successfully treated it by immediate isolation of the cerebral circulation from the systemic circulation. The surgical management, including the above technique, for this rare event is described.

Axillary artery cannulation for arterial inflow in patients with acute dissection of the ascending aorta

The axillary artery is an alternative site for arterial cannulation that avoids manipulation of the ascending aorta or aortic arch and provides antegrade blood flow during surgery for acute type A aortic dissection. Right axillary artery cannulation has been used in 27 patients for arterial perfusion. There were no complications related to the technique of axillary cannulation. All patients but one awoke neurologically intact from operation and suffered no complications. Hospital mortality occurred in two (7.4%) patients. Axillary cannulation is easy to establish and may safely be used for arterial inflow during surgery for acute type A dissection of the ascending aorta.