Cannulation strategies for aortic surgery: which is the best one?

Abstract

The choice of the optimal arterial cannulation strategy for surgery on proximal aorta and arch remains a controversial area and a subject of intense debate. The search for the best cannulation strategy for aortic surgery assumes increasing importance due to its impact on clinical outcomes. Several cannulation strategies have been proposed to establish cardiopulmonary bypass (CPB) for aortic surgery and each one of these has its pros and cons. These cannulation strategies can be broadly classified into central and peripheral cannulation strategies. Sites of central cannulation (CC) include the ascending aorta itself as well as the innominate, subclavian and axillary artery whereas femoral artery cannulation is synonymous with peripheral cannulation (PC).Traditionally, the femoral artery has been the preferred arterial cannulation site for establishing CPB for proximal aortic and arch surgery. However, more recently, femoral artery cannulation is reserved for complicated cases when aortic cannulation is deemed challenging, such as in aortic dissection or chronic proximal aortic and arch aneurysms. The decreasing reliance on routine femoral artery cannulation is secondary to the perceived increased risk of retrograde cerebral embolization, organ malperfusion, perfusion of the false lumen and retrograde dissection due to flow reversal in the thoracoabdominal aorta (1). There has been a simultaneous increase in published reports of CC with axillary artery cannulation emerging as the favoured strategy due to it being a safe and easy technique, especially in patients with a diseased ascending aorta or when femoral artery cannulation is precluded such as in the presence of aortoiliac aneurysms, severe peripheral occlusive disease, atherosclerosis of the femoral vessels, and distal extension of the aortic dissection (2).In the current era of evidence-based medicine, it is vital that strategies that are backed by current best available evidence are adopted to ensure that clinical outcomes for complex procedures such proximal aortic and arch surgery are further improved. Interestingly, there is a lack of gold standard evidence from randomized controlled trials comparing CC and PC. Majority of the evidence on the subject is in the form of observational cohort studies of variable reporting quality and conflicting results (3,4). Our group attempted to provide some clarity on the subject by undertaking a meta-analysis of comparative studies reporting operative outcomes following CC and PC (5). This meta-analysis included a total of 4,476 patients. CC was used in 2,797 cases and PC in 1,679 cases. CC showed a protective effect on in-hospital mortality (RR 0.59; 95% CI, 0.48-0.7; P<0.001) and permanent neurologic deficit (RR 0.71; 95% CI, P=0.005) when compared to PC. A trend towards an increased benefit in terms of reduced in-hospital mortality was observed when the right axillary artery only was used as CC approach (RR 0.35; 95% CI, 0.22-0.55; P<0.001; I 2 =0%) (5). This trend seems to be attributed to antegrade cerebral perfu...

Proximal arterial cannulation in thoracic aortic surgery—Literature review

“…Nevertheless, most surgeons prefer central cannulation which is AA, innominate and axillary artery cannulation rather than peripheral cannulation such as femoral artery cannulation. There has been increasing the use of axillary artery cannulation due to its safety and technical feasibility, especially in patients with diseased AA or femoral artery . Raja et al reported that femoral artery cannulation is usually reserved for challenging cases such as aortic dissection or chronic proximal aortic and arch aneurysms.…”

“…There has been increasing the use of axillary artery cannulation due to its safety and technical feasibility, especially in patients with diseased AA or femoral artery . Raja et al reported that femoral artery cannulation is usually reserved for challenging cases such as aortic dissection or chronic proximal aortic and arch aneurysms. However, the risk of retrograde cerebral embolization, organ malperfusion, perfusion of the false lumen, and retrograde dissection due to flow reversal in the thoracoabdominal aorta, can be increased by femoral cannulation .…”

“…Raja et al reported that femoral artery cannulation is usually reserved for challenging cases such as aortic dissection or chronic proximal aortic and arch aneurysms. However, the risk of retrograde cerebral embolization, organ malperfusion, perfusion of the false lumen, and retrograde dissection due to flow reversal in the thoracoabdominal aorta, can be increased by femoral cannulation . According to Di Eusanio et al, RAA cannulations has favorable outcomes after acute dissection and aneurysm repairs even though it requires a separate incision in the axilla, and it might be associated with complications such as brachial plexus injury, axillary artery damage, further dissection, and arm ischemia.…”

“…Cannulation strategies can be broadly divided into central and peripheral strategies with central strategies gaining more prominence in the current practice . Sites of central cannulations include the ascending aorta (AA), innominate artery (IA), axillary artery and, in rare occasions, direct left ventricular apical cannulation particularly in acute type A aortic dissection when there is no feasible access to the true lumen …”

“…2,3 Sites of central cannulations include the ascending aorta (AA), innominate artery (IA), axillary artery and, in rare occasions, direct left ventricular apical cannulation particularly in acute type A aortic dissection when there is no feasible access to the true lumen. 4 Thoracic aortic surgery is associated with significant morbidity and mortality rates, this is mainly attributed to the pathology and complexity of the procedure, long CPB times, deep hypothermic circulatory arrest and the interruption of perfusion to the brain and thus high chances of various insults to the nervous system. 5 Neurological injuries after aortic arch operations can be detrimental to postoperative outcomes with reported strokes rates of up to 12% of elective operations and significant cerebral dysfunction has been reported to occur in up to 25% of those patients.…”