Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach

Abstract

Objectives: Consensus regarding initial cannulation site for acute type A dissection repair is lacking. Objectives were to review our experience with systematic initial axillary artery cannulation, characterize patients on the basis of cannulation site, and assess outcomes.Methods: From January 2000 to January 2017, 775 patients underwent emergency acute type A dissection repair. Initial axillary cannulation was performed in 617 (80%), femoral in 93 (12%), and central in 65 (8.4%). In-hospital mortality and stroke risk factors were identified using logistic regression. Results:Reasons for selecting initial central or femoral instead of axillary cannulation included unsuitable axillary anatomy (n ¼ 67; 42%), surgeon preference (n ¼ 38; 24%), hemodynamic instability (n ¼ 34; 22%), and preexisting cannulation (n ¼ 19; 12%). Cannulation site was shifted or added intraoperatively in 82 (11%), with initial cannulation site being axillary (n ¼ 23 of 617; 3.7%), central (6 of 65; 9.2%), or femoral (n ¼ 53 of 93; 57%), for surgeon preference (n ¼ 60; 73%), high flow resistance (n ¼ 13; 16%), increased aortic false lumen flow (n ¼ 6; 7.3%), and other (n ¼ 3; 3.7%). In-hospital mortality was 8.6% (n ¼ 67; lowest for axillary, 7.3% [P ¼ .02]) and stroke 8.3% (n ¼ 64). Hemodynamic instability (odds ratio [OR], 7.

Cannulation strategies & circulation management in type‐A aortic dissection

“…In their series of 88 patients, in‐hospital mortality was 2% and perioperative stroke was 6%. These results are comparable to studies using other cannulation strategies 19,21,23,27 …”

“…Right axillary artery has been used as a site for arterial inflow in as many as 27% of cases in United States 15 and has been favored by some surgeons who have reported excellent results 27 . The advantage lies in achieving antegrade flow into the proximal arch, most often into the true lumen.…”

“…In a hemodynamically unstable patient, alternate access sites such as direct aortic or femoral artery may be more desirable. 27 …”

“…Many surgeons use this approach preferentially in the setting of hemodynamic instability and when preoperative imaging shows a severe dissection/disruption of the innominate artery. In most patients an anteriorly positioned true lumen is observed which allow easy accessibility of the true lumen via a needle and wire under echocardiographic guidance 27 . Other surgeons use this technique routinely even when the innominate artery is not dissected and the true lumen is more posteriorly positioned, reporting excellent results 13 .…”

Commentary: Stroke after type A aortic dissection repair—A web of risk with no single answer

“…High-volume centers of excellence report excellent outcomes with both axillary and femoral cannulation. 2,3 Rosinski and colleagues 2 demonstrate how even an axillary-first approach will sometimes require femoral cannulation, providing an insightful look into how retrospective analyses may bias against femoral cannulation in ways not easily controlled for. Also notable is the reliance of Ghoreishi and colleagues 1 on retrograde cerebral perfusion regardless of cannulation site.…”