Comparison of Single Axillary vs. Dual Arterial Cannulation for Acute Type a Aortic Dissection: A Propensity Score Matching Analysis

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

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

Single Arterial Cannulation vs. Dual Arterial Cannulation during Acute Type A Aortic Dissection Repair: A Systematic Review and Meta-Analysis

OBJECTIVE

Acute type A aortic dissection (ATAAD) is a cardiovascular emergency with high mortality and morbidity. We compared the effects on outcomes of single arterial cannulation (SAC) via axillary, femoral, or ascending aorta with double arterial cannulation (DAC) via axillary and femoral artery during ATAAD repair.

METHODS

We conducted a systematic review and meta-analysis of observational studies from PubMed, Web of Science, Scopus, EMBASE, and Cochrane searches through April 30, 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using R version 4.3. The protocol is registered on PROSPERO (CRD42024535644).

RESULTS

Our analysis included 7 studies encompassing 3,534 patients. DAC was associated with a significantly longer intensive care unit stay than SAC (MD 0.45 days, 95% CI 0.10, 0.79, p = 0.01). However, there was no significant difference between DAC and SAC in the length of hospital stay (MD 1.39 days, 95% CI -2.70, 5.47, p = 0.51). Also, there was no significant difference between the two approaches in the incidence of stroke (RR 1.12, 95% CI 0.77, 1.64, p = 0.55), paraplegia (RR 0.59, 95% CI 0.32, 1.07, p = 0.08), or acute kidney injury (RR 0.83, 95% CI 0.55, 1.24, p = 1.24).

CONCLUSION

Our meta-analysis shows that during ATAAD repair, DAC was associated with slightly longer intensive care stay, which was of doubtful clinical significance. However, both approaches were comparable for hospital stay, the incidence of stroke, paraplegia, or acute kidney injury.

IMPLICATIONS FOR CLINICAL PRACTICE

Despite comparable overall outcomes, we observed that DAC was associated with higher risks of requiring continuous renal replacement therapy or dialysis, and reintubation. This emphasizes the need to carefully consider cannulation strategies based on patient factors to balance potential benefits and risks.

Relation between uric acid and stroke in aortic dissection

Background

Stroke is one of the severe complications following surgery in patients with acute type A aortic dissection (ATAAD). This study investigates the relationship between the preoperative serum uric acid to serum creatinine ratio (SUA/Scr) and postoperative stroke in patients undergoing total arch replacement with elephant trunk implantation for aortic dissection.

Methods

We included ATAAD patients who were hospitalized and underwent surgery between June 1, 2015 and June 1, 2023, with complete clinical information. Preoperative SUA and Scr levels were collected to calculate SUA/Scr. The association between SUA/Scr and postoperative stroke was analyzed using univariate and multivariate logistic regression, as well as subgroup analysis. The optimal cut-off value of SUA/Scr was determined by receiver operating characteristic (ROC) curve analysis.

Results

A total of 332 patients were included in the study. Patients who developed postoperative stroke had lower SUA/Scr compared to those who did not (P=0.03). Univariate logistic regression indicated that higher SUA/Scr was associated with a reduced risk of postoperative stroke [odds ratio (OR) =0.80; 95% confidence interval (CI): 0.65-0.98; P=0.03]. This association remained significant after adjusting for confounding factors (OR =0.66; 95% CI: 0.45-0.97; P=0.04). Subgroup analysis revealed that the association between higher SUA/Scr and reduced risk of postoperative stroke was significant only in male patients (OR =0.81; 95% CI: 0.65-1.01; P=0.046) and those younger than 65 years (OR =0.82; 95% CI: 0.66-1.02; P=0.048), and was observed only in patients who underwent non-axillary artery cannulation (OR =0.65; 95% CI: 0.50-0.84; P=0.001), left femoral artery cannulation (OR =0.74; 95% CI: 0.58-0.96; P=0.02), and bilateral cerebral perfusion (OR =0.51; 95% CI: 0.32-0.81; P=0.004). The ROC curve analysis identified 3.36 as the optimal cut-off value for SUA/Scr.

Conclusions

A higher SUA/Scr is associated with a reduced risk of postoperative stroke in patients with aortic dissection undergoing total arch replacement with stented elephant trunk implantation and may serve as a potential predictor of postoperative stroke.

Double arterial vs. single axillary cannulation in acute type A aortic dissections: a meta-analysis

Aim: To evaluate the effects of double (axillary and femoral) vs. single (axillary) cannulation on early outcomes of acute type A aortic dissection (ATAAD). Materials & methods: Meta-analysis using PubMed/MEDLINE, Scopus, and Cochrane databases through August 23, 2023. Focused on operative mortality, postoperative stroke, re-exploration for bleeding, spinal cord injury, and renal replacement therapy. Results: Among 5 propensity score-matched studies with 2127 patients, double cannulation showed comparable mortality and higher rates of postoperative stroke (pooled odds ratio: 1.69, 95% confidence interval: 1.19-2.39) and need for renal replacement therapy (pooled odds ratio: 1.35, 95% confidence interval: 1.13-1.60) compared with single cannulation. Conclusion: Double arterial cannulation in ATAAD surgery is associated with increased postoperative stroke and renal replacement therapy than single cannulation.

Analysing debranching techniques in Frozen Elephant Trunk procedures: a narrative literature review

Background and Objective

Since 2003, the Frozen Elephant Trunk (FET) technique has attained rising popularity for treating extensive aortic arch pathologies such as acute and chronic aortic dissection, as well as thoracic aortic aneurysm. Conventionally, the FET procedure included a complete resection of the aortic arch and, subsequently, a distal aortic anastomosis of the prosthetic part of the hybrid graft in arch zone 3. Simultaneous to the introduction of the FET technique, the traditional Elephant Trunk technique was simplified by adding debranching techniques which allows for proximalization of the distal aortic anastomosis. Nowadays, modern concepts of aortic arch surgery combine the FET technique with proximalization of the distal anastomosis in arch zone 2 or further proximal, achieved by using different debranching techniques. This review describes different debranching techniques to facilitate arch reconstruction, and aims to critically assess the outcomes and potential clinical advantages of proximalization using debranching in FET surgery.

Methods

We conducted a search using the PubMed and Google Scholar electronic databases to evaluate published outcomes of different debranching techniques. An overview of the data synthesis of 21 included studies is reported.

Key Content and Findings

Most studies report numeric, but not statistically significant improved outcomes after debranching in FET surgery for mortality, neurological complications, spinal cord injury, kidney failure, bowel ischemia and recurrent nerve palsy. Some studies report statistically significant improved results in isolated endpoints such as neurological, bowel ischemia, and recurrent nerve palsy. Most studies report debranching to be technically easier, but this is difficult to objectively assess and measure.

Conclusions

There is an improved numeric outcome of different debranching techniques with proximalization of the distal anastomosis, but without reaching statistical significance. This review shows marked heterogeneity across included studies and highlights the scarce use of existing guidelines in clinical research of open aortic arch surgery as proposed by the International Aortic Arch Surgery Study Group. Furthermore, this review demonstrates the urgent need for multicenter registries or studies to be able to compare the outcome of different surgical techniques for various aortic arch pathologies.

Acute renal failure after acute type A aortic dissection repair. Insidious postoperative complication with poor short- and long-term prognosis

Acute type A aortic dissection (ATAAD) is a life-threatening aortic disease. Many systems and organs are affected by malperfusion which presents preoperatively and postoperatively. Postoperative acute renal failure after ATAAD constitutes a severe and insidious complication. Acute renal damage is observed in many patients with ATAAD preoperatively and it burdens the renal function postoperatively. Renal replacement therapy represents an additional risk factor for short-, mid-, and long-term outcomes after ATAAD repair. Brown et al.'s present study highlight the clinical significance of this complication. Also, they remind us of the importance of optimizing perioperative renal protective strategies in patients undergoing ATAAD repair.