The central role of cannulation in determining outcomes after surgery for acute type A aortic dissection: where do we stand?

Abstract

In their work, Ramaprabhu et al. [1] retrospectively analysed patients with acute type A aortic dissection (ATAAD) who underwent emergent surgery (n = 107) during a 10-year period at a single institution (from January 2008 to March 2018). The study cohort was divided into 2 groups for purposes of data analysis: group 1: direct ascending aorta cannulation (AscAo, n = 47; median age, 69 years; females 34%) versus group 2: non-aortic cannulation (non-AscAo, n = 60; median age 62 years; females 20%). The authors found no statistically significant differences in rates of major perioperative complications (such as stroke or acute kidney injury), postoperative lactate levels and long-term survival. Notwithstanding the clinical relevance of the work by Ramaprabhu et al., their findings must be put into a broader clinical perspective and viewed within the context of some notable limitations to the study methodology. First and foremost, the authors point out that the site of arterial cannulation was decided individually based on the surgeon's preference and anatomy of the dissection. Indeed, they state that owing to the ease and relatively rapid initiation of cardiopulmonary bypass, they had lately preferred to use AscAo cannulation over a guidewire under echocardiographic guidance. However, the non-AscAo cannulation was performed using several different techniques including femoral artery cannulation, axillary artery cannulation, and even double cannulation with axillary artery plus femoral artery cannulation. However, the relatively limited sample size could not allow further comparisons between the latter techniques, which remains an unaddressed question.