Safety and efficacy of central cannulation through ascending aorta for type A aortic dissection

Abstract

The femoral and axillary arteries are common arterial cannulation sites for repair of type A dissection. However, these peripheral approaches involve certain problems. From January 2002 to August 2009, a total of 77 patients underwent emergency surgery for acute type A dissection. Central cannulation was applied in 26 patients and peripheral cannulation in 51. The arterial cannulation site was decided according to preoperative computed tomography findings, the patient's condition, and intraoperative epiaortic ultrasonography findings. Central cannulation was avoided in cases of cardiac tamponade with shock. A cannula was inserted under ultrasound guidance using the Seldinger technique. Preoperative patient comorbidities and dissection-related complications were equally distributed between the two groups. Central cannulation was successfully performed in all 26 cases without incident. Operation time, cardiopulmonary bypass time, mean intubation time and mean intensive care unit stay duration were significant shorter in the central group. One patient (4%) died in the central group compared with four patients (8%) in the peripheral group (P=0.45). Direct central cannulation was successful for repair of type A dissection in selected patients and produced equal or superior surgical data to peripheral cannulation, thus providing one option in the approach to this condition.

Surgical management and outcomes of type A dissection—the Mayo Clinic experience

“…Patient's hemodynamic stability, extent of dissection, level of the planned distal repair and surgeon's preference are some of the selection variables that determine the choice (9,22,23).…”

“…It is relatively rapid to access, but it is associated with retrograde debris embolization, further dissection of intimal flap, expansion of the false lumen, and potential organ malperfusion (9,23). Axillary artery cannulation has the advantage of delivering cerebral perfusion through the initial cannulation site.…”

“…Axillary artery cannulation has the advantage of delivering cerebral perfusion through the initial cannulation site. There is less risk for visceral malperfusion, but it can be technically demanding in large patients, requires a separate incision, has been associated with brachial plexus injury and arm ischemia, and can cause insufficient systemic CPB flow if the vessel is small, has a serpentine course, atherosclerotic, or is itself dissected (9,13,23,24). Innominate artery cannulation, first described by Banbury and Cosgrove in 2000, is less commonly used (23).…”

“…These include the most efficient cannulation technique, appropriate aortic root management, and extent of distal repair. Despite diminishing reliance on the femoral artery, there has been no consensus on the best arterial cannulation technique with the lowest complication rate that could shorten operative times (9). Proponents of a more conservative root management and extent of distal repair claimed that early survival is improved by reducing the complexity of the surgery, a gain that is offset by the higher risk of reoperation when diseased aortic tissue is left in situ (1,7,8,10).…”

Direct and Transapical Central Cannulation for Acute Type A Aortic Dissection

“…[12][13][14] Furthermore, the use of cannulation of the ascending aorta to treat acute aortic dissection has also been reported. 4,5,15,16) Some institutions (such as ours) use the Seldinger technique for artery puncture and cannulation, 15,17) while others use direct cannulation for ordinary open heart surgery. 5,16) Both methods have been reported to be useful.…”