A Retrospective Cohort Study Comparing Different Cannulation Strategies in Type A Aortic Dissection Surgery: 20-year Single-Center Experience in a Referral Center

Abstract

Background

Type A aortic dissection as a highly lethal disease continues being a great challenge for cardiac surgeons worldwide. There are still unanswered questions regarding intraoperative decisions and their impact on the surgical outcomes. The aim of this study is to compare postoperative outcomes according to site of cannulation in patients with acute Type A aortic dissection (ATAAD).

Methods

This was a retrospective cohort study. We included all ATAAD procedures from January 2002 to November 2023. We defined groups according to site of cannulation (aorta, axillary, femoral, innominate). Data from pre-, intra-, and postoperative variables were collected. Our main outcomes were spinal cord injury (SCI), stroke rate, and in-hospital mortality. Between-group comparisons were performed using standard statistical tests and post hoc tests adjusting for multiple comparisons were performed.

Results

We identified 127 ATAAD procedures. Reoperation for bleeding was significantly higher in the femoral cannulation group (75%, p = 0.0006). There were no statistically significant differences in acute kidney injury rate (p = 0.012), SCI rate (p = 0.78), or in-hospital mortality (p = 0.75). Our data suggest that there is a lower stroke rate in the axillary cannulation group (3.6%, p = 0.4), which did not reach statistical significance.

Conclusion

Choosing an adequate cannulation site is a critical step in TAAD surgery. In our series, axillary and innominate cannulation were the preferred methods with relatively low complication rates.

Keywords

Type A aortic dissection - cannulation strategy - stroke - spinal cord injury

Publication History

Received: 11 December 2023

Accepted: 10 October 2024

Article published online:
17 February 2025

• References

• 1 Abe T, Usui A. The cannulation strategy in surgery for acute type A dissection. Gen Thorac Cardiovasc Surg 2017; 65 (01) 1-9
• 2 Keeling WB, Chen EP. Maxing out the axillary artery for arterial cannulation in acute type A dissection. J Thorac Cardiovasc Surg 2016; 152 (03) 808-809
• 3 Sun YX, Meng ML, Li G, Guo HW. Left axillary cannulation for acute type A aortic dissection. J Cardiothorac Surg 2022; 17 (01) 188
• 4 Ram E, Krupik Y, Lipey A. et al. Is axillary better than femoral artery cannulation in repair of acute type A aortic dissection?. Innovations (Phila) 2019; 14 (02) 124-133
• 5 Kong X, Ruan P, Yu J, Jiang H, Chu T, Ge J. Innominate artery direct cannulation provides brain protection during total arch replacement for acute type A aortic dissection. J Cardiothorac Surg 2022; 17 (01) 165
• 6 Lemaire A, Levine D, Chao J. et al. Does arterial cannulation site for aortic dissection repair impact surgical outcomes?. J Thorac Dis 2023; 15 (03) 1057-1062
• 7 Patris V, Toufektzian L, Field M, Argiriou M. Is axillary superior to femoral artery cannulation for acute type A aortic dissection surgery?. Interact Cardiovasc Thorac Surg 2015; 21 (04) 515-520
• 8 Xia Q, Cao Y, Xie B. et al. Cannulation strategies in type A aortic dissection: a novel insight narrative review. J Thorac Dis 2021; 13 (04) 2551-2562
• 9 Choudhary SK, Reddy PR. Cannulation strategies in aortic surgery: techniques and decision making. Indian J Thorac Cardiovasc Surg 2022; 38 (Suppl. 01) 132-145
• 10 Xie Y, Liu Y, Yang P, Lu C, Hu J. Comparison of post-operative outcomes between direct axillary artery cannulation and side-graft axillary artery cannulation in cardiac surgery: a systematic review and meta-analysis. Front Cardiovasc Med 2022; 9: 925709
• 11 Stamou SC, Gartner D, Kouchoukos NT. et al. Axillary versus femoral arterial cannulation during repair of type A aortic dissection?: an old problem seeking new solutions. Aorta (Stamford) 2016; 4 (04) 115-123
• 12 Ohno N, Minatoya K. Arterial cannulation to establish cardiopulmonary bypass during surgery for acute aortic dissection. Surg Today 2020; 50 (11) 1353-1359
• 13 Czerny M, Grabenwöger M, Berger T. et al; Authors/Task Force Members, EACTS/STS Scientific Document Group. EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Ann Thorac Surg 2024; 118 (01) 5-115
• 14 Malaisrie SC, Szeto WY, Halas M. et al; AATS Clinical Practice Standards Committee: Adult Cardiac Surgery. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162 (03) 735-758.e2
• 15 Isselbacher EM, Preventza O, Hamilton Black III J. et al; Peer Review Committee Members. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines. Circulation 2022; 146 (24) e334-e482
• 16 MacGillivray TE, Gleason TG, Patel HJ. et al. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163 (04) 1231-1249
• 17 Kreibich M, Chen Z, Rylski B. et al. Outcome after aortic, axillary, or femoral cannulation for acute type A aortic dissection. J Thorac Cardiovasc Surg 2019; 158 (01) 27-34.e9
• 18 Fusco DS, Shaw RK, Tranquilli M, Kopf GS, Elefteriades JA. Femoral cannulation is safe for type A dissection repair. Ann Thorac Surg 2004; 78 (04) 1285-1289 , discussion 1285–1289
• 19 Hou XT, Sun YQ, Zhang HJ, Zheng SH, Liu YY, Wang JG. Femoral artery cannulation in Stanford type A aortic dissection operations. Asian Cardiovasc Thorac Ann 2006; 14 (01) 35-37
• 20 Hussain A, Uzzaman M, Mohamed S, Khan F, Butt S, Khan H. Femoral versus axillary cannulation in acute type A aortic dissections: a meta-analysis. J Card Surg 2021; 36 (10) 3761-3769
• 21 Ohira S, Malekan R, Kai M. et al. Direct axillary artery cannulation for type A dissection and impact of dissected innominate artery. Ann Thorac Surg 2022; 113 (04) 1183-1190
• 22 Zhang H, Xie W, Lu Y. et al. Double arterial cannulation versus right axillary artery cannulation for acute type A aortic dissection: a retrospective study. J Cardiothorac Surg 2021; 16 (01) 326
• 23 Harky A, Chan JSK, Bithas C. et al. Innominate vs. axillary artery cannulation in aortic surgery: a systematic review and meta-analysis. Braz J Cardiovasc Surg 2019; 34 (02) 213-221
• 24 Rosinski BF, Idrees JJ, Roselli EE. et al. Cannulation strategies in acute type A dissection repair: a systematic axillary artery approach. J Thorac Cardiovasc Surg 2019; 158 (03) 647-659.e5
• 25 Huang L-C, Xu Q-C, Chen D-Z, Dai X-F, Chen L-W. Combined femoral and axillary perfusion strategy for Stanford type A aortic dissection repair. J Cardiothorac Surg 2020; 15 (01) 326
• 26 Harky A, Wong CHM, Chan JSK, Zaki S, Froghi S, Bashir M. Innominate artery cannulation in aortic surgery: a systematic review. J Card Surg 2018; 33 (12) 818-825