EComment. Acute aortic dissection type A: which strategy of the arterial perfusion to choose?

Abstract

We read with the great interest the report of Conzelmann and colleagues [1], describing the original method of direct aortic cannulation and we congratulate the authors for their excellent results. However, the separation between the adventitial layers of the ascending aorta and the pulmonary artery can lead to rupture of the aorta in this area. In addition, direct cannulation of the true aortic can be complicated by thromboembolism in the case of the false lumen thrombosis. Inadequate organ perfusion is one of the major problems in patients with acute type A aortic dissection (AADA). Until recently, the retrograde perfusion via the femoral artery was the perfusion mode of choice in thoracic aortic surgery [2]. But in some cases, this was marked by a high risk of potential malperfusion and atheroembolic complications associated with retrograde perfusion, especially in dissections. In recent years, subclavian artery cannulation for AADA has become a widely accepted arterial access for antegrade aortic and cerebral perfusion [3,4]. Surgical exposure of the subclavian artery is easy to perform, and if the operative field and the patient are routinely prepared for this procedure, it is rapidly performed. At our institute, 148 patients with AADA underwent surgery. As of 2004, we have been using the subclavian arterial perfusion in the majority of patients. This has led to a significant reduction in the incidence of postoperative multiple organ failure, and has reduced hospital mortality (from 24% to 8-10% in recent years). In our practice, surgical exposure and cannulation of subclavian artery usually require an additional 5-10 minutes, but in any case, it does not affect the outcome of the operation. We have rarely found heavily diseased subclavian arteries and involvement of a subclavian artery by the dissection process is also rare. In addition, the use of this technique facilitates the work of the surgeon at the expense of absence of arterial cannula in a working zone, as well as reduces the risk of embolic complications. All this, in our opinion, makes this method more preferable. However, in emergency situations with highly unstable haemodynamics or in case of dissections extending into the innominate artery, the method described by the authors may be useful [1]. In conclusion, we would like to note that the ascending aortic cannulation of the true lumen under direct vision deserves serious consideration as a safe and rapid way to ensure antegrade arterial perfusion in same unstable patients with acute type A dissection. However, this method requires further study.