Double-arterial cannulation strategy in patients presenting with Type A aortic dissection

Abstract

Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality. Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality. Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes. Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs. Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.