Abstract
BackgroundDirect cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection.MethodsA multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis.ResultsSeventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%).ConclusionsThis study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.
Highlights
Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions
Several techniques for administering selective antegrade cerebral perfusion (ACP) (SACP) have been described including right axillary artery cannulation with concomitant occlusion of the base of the innominate artery [9], direct placement of balloon-tipped catheters into the ostia of the arch vessels [10], and cannulation of the innominate artery via a side-graft [11, 12]. Neurologic events with these techniques range from 3.4% in elective aortic arch operations to 12% in acute Stanford type A dissections
Early mortality in patients undergoing surgical repair of type A aortic dissection is reported as high as 31%. (3) Developing an efficient and safe surgical technique to cannulate and provide cerebral perfusion is essential to successfully perform a repair of type A aortic dissection pathology
Summary
Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. Several techniques for administering selective ACP (SACP) have been described including right axillary artery cannulation with concomitant occlusion of the base of the innominate artery [9], direct placement of balloon-tipped catheters into the ostia of the arch vessels [10], and cannulation of the innominate artery via a side-graft [11, 12]. Neurologic events with these techniques range from 3.4% in elective aortic arch operations to 12% in acute Stanford type A dissections. An alternative technique for SACP, utilizing direct innominate artery cannulation, has been shown to be safe in elective arch reconstruction with reported stroke and mortality rates of 1% [13, 14]
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