Direct aortic cannulation, a safe alternative to femoral artery cannulation - 17 years of type A dissection surgery experience

Abstract

Aim: Optimal cannulation strategy for acute type A aortic dissection (ATAAD) surgery remains debated. Recent guidelines have advocated antegrade systemic perfusion through right axillary artery (RAX) cannulation, instead of femoral artery (FA) cannulation. However, RAX cannulation can be technically challenging and time-consuming. On the other hand, direct (ascending) aorta (DA) cannulation is a swift procedure that also ensures downstream antegrade flow. In this regard, we assessed whether DA cannulation is a safe alternative to FA cannulation.

Methods: Records of all patients undergoing ATAAD surgery between 2006-2022 at the Radboud University Medical Center were retrospectively reviewed.

Results: In total, 281 patients underwent surgery for ATAAD during the investigated period. Three patients were excluded due to death before the start of extracorporeal circulation and four because of RAX cannulation. Of the remaining 274 patients, 53% (N = 145) received primary FA and 47% (N = 129) DA cannulation, with a success rate of 98% for both approaches. Surgical mortality (combined in-hospital and 30-day) was 9.9% (7.8% DA group vs. 11.7% FA group, P = 0.271). New permanent neurological damage was seen in 10.9% vs. 6.9% (P = 0.248), respectively. In multivariate analysis, cannulation strategies were not significantly associated with surgical mortality nor postoperative new permanent neurological damage.

Conclusion: DA cannulation offers a safe and fast alternative to FA cannulation in ATAAD surgery. There were no significant differences in mortality and neurological complications. Future studies should focus on the differences between RAX and DA cannulation strategies on postoperative outcomes in ATAAD surgery.

Keywords

Type A dissection / cannulation / axillary artery / direct aorta / femoral artery / extracorporeal circulation

References

[1] Pape LA,Woznicki EM.Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection.J Am Coll Cardiol2015;66:350-8

[2] Lee TC,Cheema FH.Contemporary management and outcomes of acute type A aortic dissection: an analysis of the STS adult cardiac surgery database.J Card Surg2018;33:7-18

[3] Lin CY,Tseng CN.Surgical outcomes analysis in patients with uncomplicated acute type A aortic dissection: a 13-year institutional experience.Sci Rep2020;10:14883 PMCID:PMC7484816

[4] Conzelmann LO,Mehlhorn U.GERAADA InvestigatorsMortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German registry for acute aortic dissection type A (GERAADA).Eur J Cardiothorac Surg2016;49:e44-52

[5] Anagnostopoulos CE,Kittle CF.Aortic dissections and dissecting aneurysms.Am J Cardiol1972;30:263-73

[6] Bekkers JA,Takkenberg JJ.Acute type A aortic dissection: long-term results and reoperations.Eur J Cardiothorac Surg2013;43:389-96

[7] Erbel R,Boileau C.ESC Committee for Practice Guidelines2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European society of cardiology (ESC).Eur Heart J2014;35:2873-926

[8] Gudbjartsson T,Geirsson A.Acute type A aortic dissection - a review.Scand Cardiovasc J2020;54:1-13

[9] McClure RS,Boodhwani M.Cause of death following surgery for acute type A dissection: evidence from the Canadian thoracic aortic collaborative.Aorta2017;5:33-41 PMCID:PMC5570566

[10] Shimokawa T,Ozawa N.Management of intraoperative malperfusion syndrome using femoral artery cannulation for repair of acute type A aortic dissection.Ann Thorac Surg2008;85:1619-24

[11] de Paulis R, Czerny M, Weltert L, et al; EACTS Vascular Domain Group. Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe.Eur J Cardiothorac Surg2015;47:917-23

[12] Van Arsdell GS, David TE, Butany J. Autopsies in acute type A aortic dissection. Surgical implications.Circulation1998;98:II299-302

[13] Benedetto U,Amrani M.The impact of arterial cannulation strategy on operative outcomes in aortic surgery: evidence from a comprehensive meta-analysis of comparative studies on 4476 patients.J Thorac Cardiovasc Surg2014;148:2936-43.e4

[14] Ren Z,Hu R.Which cannulation (axillary cannulation or femoral cannulation) is better for acute type A aortic dissection repair? A meta-analysis of nine clinical studies.Eur J Cardiothorac Surg2015;47:408-15

[15] Benedetto U,Vitulli P.Axillary versus femoral arterial cannulation in type A acute aortic dissection: evidence from a meta-analysis of comparative studies and adjusted risk estimates.Eur J Cardiothorac Surg2015;48:953-9

[16] Ghoreishi M,Cameron DE.Factors associated with acute stroke after type A aortic dissection repair: an analysis of the society of thoracic surgeons national adult cardiac surgery database.J Thorac Cardiovasc Surg2020;159:2143-54.e3

[17] Malaisrie SC,Halas M.AATS Clinical Practice Standards Committee: Adult Cardiac Surgery2021 the American association for thoracic surgery expert consensus document: surgical treatment of acute type A aortic dissection.J Thorac Cardiovasc Surg2021;162:735-58.e2

[18] Khaladj N,Peterss S.Ascending aortic cannulation in acute aortic dissection type A: the Hannover experience.Eur J Cardiothorac Surg2008;34:792-6

[19] Tiwari KK,Bevilacqua S.Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery?.Interact Cardiovasc Thorac Surg2010;10:797-802

[20] Khwaja A.KDIGO clinical practice guidelines for acute kidney injury.Nephron Clin Pract2012;120:c179-84

[21] Chiappini B,Tan E.Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients.Eur Heart J2005;26:180-6

[22] Krüger T,Hoffmann I,Aebert H.GERAADA InvestigatorsCerebral protection during surgery for acute aortic dissection type A: results of the German Registry for acute aortic dissection type A (GERAADA).Circulation2011;124:434-43

[23] Santamaria V,Vinciguerra M,Greco E.Predictors for outcome in type A aortic dissection: a focus on false lumen.Cirugía Cardiovasc2021;28:71-6

[24] Kamiya H,Halmer D.Comparison of ascending aorta versus femoral artery cannulation for acute aortic dissection type A.Circulation2009;120:S282-6

[25] Jormalainen M,Mustonen C.Direct aortic versus peripheral arterial cannulation in surgery for type A aortic dissection.Ann Thorac Surg2020;110:1251-8

[26] Reece TB,Smith RL.Central cannulation is safe in acute aortic dissection repair.J Thorac Cardiovasc Surg2007;133:428-34

[27] Kreibich M,Rylski B.Outcome after aortic, axillary, or femoral cannulation for acute type A aortic dissection.J Thorac Cardiovasc Surg2019;158:27-34.e9

[28] Sabashnikov A,Deppe AC.Axillar or aortic cannulation for aortic repair in patients with stanford A dissection?.Ann Thorac Surg2016;102:787-94

[29] Ramaprabhu K,Dearani J.Cannulation strategies for acute type A dissection-role of central cannulation.Eur J Cardiothorac Surg2022;62:ezac207

[30] Ram E,Lipey A.Is axillary better than femoral artery cannulation in repair of acute type A aortic dissection?.Innovations2019;14:124-33

[31] Schachner T,Zimmer A,Bonatti J.Technical problems and complications of axillary artery cannulation.Eur J Cardiothorac Surg2005;27:634-7