Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe

Paulis, Ruggero De; Czerny, Martin; Weltert, Luca; Bavaria, Joseph E.; Borger, Michael A.; Carrel, Thierry; Etz, Christain D.; Grimm, Michael; Loubani, Mahmoud; Pacini, Davide; Resch, Timothy; Urbanski, Paul P.; Weigang, Ernst

doi:10.1093/ejcts/ezu284

Cited by 145 publications

(112 citation statements)

References 24 publications

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“…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).…”

Section: Cannulation Techniquementioning

confidence: 99%

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

Cabasa¹,

Pochettino²

2016

Ann. Cardiothorac. Surg.

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Background: Type A aortic dissection (TAAD) is a complex cardiovascular disease that is associated with high perioperative morbidity and mortality. The most effective approach is still being debated-such as the best cannulation technique, and conservative versus extensive initial surgery. We reviewed our experience over the last 20 years and examined for variables that correlated with observed outcomes.Methods: All patients who underwent TAAD repair were reviewed. Chi-Square tests, Fisher Exact tests and Wilcoxon tests were performed where appropriate. Survival and freedom from reoperations were analyzed with the Kaplan-Meier actuarial method.Results: Acute TAAD was associated with a higher incidence of permanent stroke (P=0.010), renal failure (P=0.025), prolonged mechanical ventilator support (P=0.004), higher operative mortality (P=0.039) and higher 30-day mortality (P=0.003) compared to chronic TAAD. There was a trend towards higher risk for transient neurologic events among patients who were reoperated on (P=0.057). Extensive proximal repair led to longer perfusion and cross clamp times (P<0.001) and the need for temporary mechanical support postoperatively (P=0.011). More patients that had extensive distal repair underwent circulatory arrest (P=0.009) with no significant differences in the incidence of peri-operative complications, early, middle and long-term survival compared to the conservative management group. Overall survival in our series was 66.73% and 46.30% at 5 and 10 years respectively (median survival time: 9.38 years). There was a significant improvement in operative mortality (P=0.002) and 30-day mortality (P=0.033) in the second decade of our study.Conclusion: TAAD is a complex disease with several options for its surgical management. Each technique has its own advantages and complications and surgical management should be individualized depending on the clinical presentation. We propose our present approach to maximize benefits in both the short and long term.

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Section: Cannulation Techniquementioning

confidence: 99%

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

Cabasa¹,

Pochettino²

2016

Ann. Cardiothorac. Surg.

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“…However, according to a survey conducted in Europe in 450 centers, it was found that in 60% of the cases are still used (63).…”

Section: Methods Of Pharmacological Cerebral Protectionmentioning

confidence: 99%

Intraoperative care for aortic surgery using circulatory arrest

et al. 2017

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Abstract:The total circulatory arrest (CA) is necessary to achieve optimal surgical conditions in certain aortic pathologies, especially in those affecting the ascending aorta and aortic arch. During this procedure it is necessary to protect all the organs of ischemia, especially those of the central nervous system and for this purpose several strategies have been developed. The first and most important protective method is systemic hypothermia. The degree of hypothermia and the route of application have been evolving and currently tend to use moderate hypothermia (MH) (20.1-28 ℃) associated with unilateral or bilateral selective cerebral perfusion methods. In this way the neurological results are better, the interval of security is greater and the times of extracorporeal circulation are smaller. Even so, it is necessary to take into account that there is the possibility of ischemia in the lower part of the body, especially of the abdominal viscera and the spinal cord, therefore the time of circulatory stop should be limited and not to exceed 80 minutes. Evidence of possible neurological drug protection is very weak and only mannitol, magnesium, and statins can produce some benefit. Inhalational anesthetics and some intravenous seem to have advantages, but more studies would be needed to test their long-term benefit. Other important parameters to be monitored during these procedures are blood glucose, anemia and coagulation disorders and acid-base balance. The recommended monitoring is common in complex cardiovascular procedures and it is of special importance the neurological monitoring that can be performed with several techniques, although currently the most used are Bispectral Index (BIS) and Near-Infrared Spectroscopy (NIRS). It is also essential to monitor the temperature routinely at the nasopharyngeal and bladder level and it is important to control coagulation with rotational thromboelastometry (ROTEM).

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“…The increasing experience with axillary cannulation has, in recent years, encouraged the use of the innominate artery as a site for cannulation in an attempt to reduce the number of incisions and further simplify the procedure (6). More importantly, antegrade body perfusion as a result of axillary cannulation decreases the risk of retrograde flow both in the acute setting (malperfusion) and in the chronic condition (atheroembolism) (7).…”

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confidence: 99%

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

Raja

2017

J. Thorac. Dis.

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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...

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Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe

Abstract: These data represent a snapshot of the strategies used for cerebral protection during major aortic surgery in current practice, and may serve as a reference for standardization and refinement of different approaches.

Cited by 145 publications

References 24 publications

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

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

Intraoperative care for aortic surgery using circulatory arrest

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

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