Cannulation techniques in aortic surgery.

Abstract

Providing an adequate perfusion during aortic surgery is crucial for a satisfactory result. For this purpose, different access routes have been used for arterial cannulation including ascending aorta, innominate artery, aortic arch, carotid artery, femoral artery, subclavian or axillary artery [1–3]. The current report by Misfeld and Bakhtiary [4] clearly demonstrates the technique for direct cannulation of the subclavian and axillary artery for aortic surgery. They recommend the routine use of one of these two sites for arterial cannulation during aortic repairs. Also other possible uses for these sites were described as minimally invasive operations, reoperations and left ventricular assist device support. The use of axillary cannulation is remarked to be easier in the setting of pacemaker devices and obese patients. Femoral artery access, being accepted as a straightforward, time-effective and emergency route, has been the choice of arterial cannulation site for many years especially for aortic dissection operations. However, clinical benefits of antegrade cerebral perfusion with either axillary or subclavian cannulation have been demonstrated since mid-1990s [1]. The initial reports focused on the feasibility, short-term mortality and early neurological functions and showed better outcome [1, 2]. In a recent meta-analysis, Ren et al. [1] demonstrated significantly decreased early mortality (6.7 vs 21.6%) and a lower rate of neurological dysfunction (14.3 vs 26.4%) in axillary cannulation when compared with femoral cannulation. Moreover, in a recent report from Etz et al. [5], retrograde perfusion with femoral artery access was found to be an independent risk factor for late mortality (HR = 2; P = 0.009); antegrade perfusion via the axillary artery or direct aortic cannulation was reported with superior long-term survival compared with retrograde perfusion at 10 years after discharge (71 vs 51%). These data suggest that axillary or subclavian artery cannulation for aortic surgery, especially in acute settings, offers superior clinical results. In accordance with this finding, these cannulation routes are being more frequently used. As reported by De Paulis et al. [3], currently the preferred arterial cannulation site as a first choice for aortic arch operations is the subclavian/axillary artery access (with a rate of 54% for acute and 48% for chronic pathologies) in Europe. However, there is still no randomized trial reported on this subject. Although the current data support the use of axillary/subclavian artery cannulation during aortic surgery, recommendation for a routine practice needs still evidence. Thus, we may conclude that axillary/subclavian route can be the preferred method for arterial cannulation for aortic surgery, and it is reasonable to expect more tendency to use these access sites not only for aortic surgery but also for minimally invasive mitral and aortic valve procedures in the near future. But, currently it may also be acceptable to determine the cannulation strategy according to the patient and institutional characteristics besides surgeons’ experience and preferences.