Axillary artery cannulation reduces early embolic stroke and mortality after open arch repair with circulatory arrest

Abstract

Objective: To evaluate the efficacy of axillary artery cannulation for early embolic stroke and operative mortality, we retrospectively compared the outcomes between patients with or without axillary artery cannulation during open aortic arch repair with circulatory arrest.Methods: Between January 2004 and December 2017, 468 patients underwent open aortic arch repair with circulatory arrest using antegrade cerebral perfusion and were divided into 2 groups according to the site of arterial cannulation: the axillary artery (axillary group, n ¼ 352) or another site (nonaxillary group, n ¼ 116) groups. Embolic stroke was defined as a physician-diagnosed new postoperative neurologic deficit lasting more than 72 hours, generally confirmed by computed tomography or magnetic resonance imaging.Results: After propensity score matching, the patients' characteristics were comparable between the groups (n ¼ 116 in each). The incidences of acute type A dissection, aortic rupture, shock, or emergency operation were similar between groups. The incidence of early embolic stroke was significantly lower in axillary group (n ¼ 3 [2.6%] vs n ¼ 10 [8.6%]; P ¼ .046). Also, 30-day mortality (n ¼ 3 [2.6%] vs n ¼ 10 [8.6%]; P ¼ .046) and in-hospital mortality (n ¼ 3 [2.6%] vs n ¼ 11 [9.5%]; P ¼ .027) occurred significantly lower in the axillary group. Conclusions: Axillary artery cannulation reduced the early embolic stroke and early mortality after open arch repair with circulatory arrest. Axillary artery cannulation as the arterial cannulation site during open arch repair with circulatory arrest may be helpful in preventing embolic stroke and reducing early mortality.

Commentary: Does right axillary artery cannulation prevent aorto-cerebral embolic phenomena?

“…In this month's issue of the Journal, Kim and colleagues 1 present their retrospective analysis evaluating, by means of a propensity score-matching technique, the rate of early stroke and mortality after aortic arch replacement with right axillary cannulation compared with nonaxillary cannulation. Kim and colleagues 1 from Seoul are to be congratulated both for the results demonstrated and for their thoughtful analysis.…”

“…In this month's issue of the Journal, Kim and colleagues 1 present their retrospective analysis evaluating, by means of a propensity score-matching technique, the rate of early stroke and mortality after aortic arch replacement with right axillary cannulation compared with nonaxillary cannulation. Kim and colleagues 1 from Seoul are to be congratulated both for the results demonstrated and for their thoughtful analysis. This article is timely because the issue of determining the optimal cannulation strategy for arch reconstruction remains unresolved, with distinctly inadequate high-quality, in terms randomized, controlled trialderived, large-volume data to draw conclusions.…”

Reply: Finding the best option of the cannulation site

“…I completely agree with the conclusion in the letter by Harky and colleagues. 1 The use of the axillary artery cannulation in aortic arch surgery should not be overstated. The authors imply the superiority of the innominate artery cannulation to the axillary cannulation.…”

Reply: Alternative arterial cannulation in aortic arch surgery

“…5 Particularly since the technique has evolved to include end-to-side anastomosis of a Dacron polyester fabric graft through which cannulation occurs, there is no period of distal ischemia in the right upper extremity and lower incidence of injury to the artery as a result of direct cannulation. 6 In a notable study in a recent volume of the Journal, Kim and colleagues, 7 with a propensity score-matched analysis, showed lower incidence of embolic stroke and operative mortality after axillary artery cannulation when compared with femoral or direct aortic cannulation for arch replacement with circulatory arrest. This is certainly compelling evidence that, for most institutions, axillary should be the cannulation site of choice during arch replacement.…”

“…As Dr Gleason 8 reminds readers in his commentary on the article of Kim and colleagues, 7 readers should remember that the ideal cannulation site has not been adjudicated in large volume randomized, controlled trials. Thoracic aortic surgeons should therefore certainly keep an open mind to alternative approaches that may prove to be the superior strategy.…”