Cannulation In Acute Type Research Articles

Central (Aortic) Cannulation versus Peripheral (Axillary or Femoral) Cannulation in Acute Type A Aortic Dissections: A Meta-Analysis of Comparative Studies.

There has been an increased interest in using antegrade cannulation techniques during surgery for type A aortic dissection. While the utilization of central artery cannulation has been on the rise in recent times, its effectiveness and safety still require thorough examination. This study aimed to explore both the efficiency and safety of central arterial cannulation. A meta-analysis was conducted on studies that evaluated surgical outcomes when using central artery cannulation (CAC) in comparison to axillary artery cannulation (AXC) or femoral artery cannulation (FAC). 10 retrospective observational studies were included, enrolling 3022 patients (CAC = 1208 vs. FAC = 606; CAC = 1051 vs. AXC = 1119). Among these, 4 articles involved axillary artery cannulation, femoral artery cannulation, and central artery cannulation. Central cannulation was linked to decreased short-term mortality [odds ratio, 0.66, 95% confidence interval (CI) (0.48, 0.89), 2 = 3.27, p = 0.007; = 0; p = 0.86] compared to femoral cannulation. Additionally, central cannulation was associated with a lower occurrence of temporary neurological dysfunction (TND) [odds ratio, 0.57, 95% CI (0.38, 0.85), 2 = 0.88, p = 0.006; = 0%, p = 0.83] when compared with femoral cannulation. However, there was no statistical significance in mortality and TND between the central cannulation and axillary cannulation groups. This meta-analysis reveals that central cannulation surpasses femoral cannulation in lowering short-term mortality and the occurrence of TND among patients undergoing surgery for type A acute aortic dissection. However, central cannulation does not exhibit a higher mortality and TND compared to axillary cannulation.

Double arterial vs. single axillary cannulation in acute type A aortic dissections: a meta-analysis.

Aim: To evaluate the effects of double (axillary and femoral) vs. single (axillary) cannulation on early outcomes of acute type A aortic dissection (ATAAD). Materials & methods: Meta-analysis using PubMed/MEDLINE, Scopus, and Cochrane databases through August 23, 2023. Focused on operative mortality, postoperative stroke, re-exploration for bleeding, spinal cord injury, and renal replacement therapy. Results: Among 5 propensity score-matched studies with 2127 patients, double cannulation showed comparable mortality and higher rates of postoperative stroke (pooled odds ratio: 1.69, 95% confidence interval: 1.19-2.39) and need for renal replacement therapy (pooled odds ratio: 1.35, 95% confidence interval: 1.13-1.60) compared with single cannulation. Conclusion: Double arterial cannulation in ATAAD surgery is associated with increased postoperative stroke and renal replacement therapy than single cannulation.

Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data

BackgroundCannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD). MethodsThe study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral. ResultsThe proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia. ConclusionsAxillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.

Right axillary artery cannulation in acute type A aortic dissection with involvement of the right axillary artery

ObjectiveThe right axillary artery is currently recommended for arterial cannulation in surgery for acute type A aortic dissection. However, the feasibility of cannulation on a dissected right axillary artery remains undetermined. The objective was to examine the feasibility of cannulation on a dissected right axillary artery. MethodsFrom 2016 to 2020, 835 patients who underwent acute type A aortic dissection repair were included in this study. Cannulation strategy and perioperative outcomes of patients who did and did not have right axillary artery dissection were compared. Propensity score matching and logistic regression were applied. ResultsA total of 124 patients had right axillary artery dissection, and 711 patients did not. Direct right axillary artery cannulation was used for cardiopulmonary bypass in the majority of patients, but with a lower rate in patients with right axillary artery dissection (n = 88 [71.0%] vs n = 579 [81.4%], P = .007). Right axillary artery cannulation failure (n = 3 [2.4%] vs n = 5 [0.7%], P = .102) and related complications (n = 1 [0.8%] vs n = 6 [0.8%], P = 1.000) were rare in both groups. In-hospital mortality (n = 18 [14.5%] vs n = 59 [8.3%], P = .027) and stroke (n = 14 [11.3%] vs n = 42 [5.9%], P = .027) were significantly higher in the right axillary artery dissection group, but after propensity score matching, in-hospital outcomes were comparable. Right axillary artery dissection was not a risk factor for mortality, stroke, right axillary artery cannulation not performed, or right axillary artery cannulation failure. ConclusionsDirect right axillary artery cannulation is feasible for most patients with acute type A aortic dissection with right axillary artery dissection.

Aortic and arch branch vessel cannulation in acute type A aortic dissection repair.

ObjectiveTo evaluate central aortic cannulation and arch branch vessel (ABV) cannulation in acute type A aortic dissection repair.MethodsFrom 2015 to April 2020, 298 patients underwent open repair of an acute type A aortic dissection. Patients undergoing femoral cannulation for cardiopulmonary bypass (n = 34) were excluded. Patients were then divided based on initial cannulation for cardiopulmonary bypass into central aortic cannulation (n = 72) and ABV cannulation (n = 192) groups. ABV sites included cannulation of the axillary, innominate, right/left common carotid, and intrathoracic right subclavian arteries.ResultsThe aortic cannulation group was younger (59 vs 62 years; P = .02), more likely to be men (76% vs 60%; P = .02), and had more peripheral vascular disease (60% vs 37%; P = .0009). ABV dissection was similar between central and ABV cannulation groups (53% vs 60%; P = .51). The aortic cannulation group underwent less aggressive arch replacement, had shorter cardiopulmonary bypass times (200 vs 222 minutes; P = .01), less utilization of antegrade cerebral perfusion (93% vs 98%; P = .04), and received less blood transfusion (0 vs 1 U; P = .001). Postoperative outcomes were similar between aortic and ABV cannulation groups, including stroke (5.6% vs 5.2%; P = 1.0) and operative mortality (4.2% vs 6.3%; P = .77). In addition, postoperative strokes were similar in location (right-brain, left-brain, or bilateral), etiology (embolic vs hemorrhagic), and presence of permanent deficits. Aortic cannulation was not a risk factor for postoperative stroke (odds ratio, 0.94; P = .91) or operative mortality (odds ratio, 0.70; P = .64). Short-term survival was similar between central and ABV cannulation groups.ConclusionsBoth aortic and ABV cannulation were safe and effective cannulation strategies in acute type A aortic dissection repair.

Double arterial cannulation versus right axillary artery cannulation for acute type A aortic dissection: a retrospective study

BackgroundCannulation strategy in surgery for acute type A aortic dissection (ATAAD) remains controversial. We aimed to retrospectively analyze the safety and efficacy of double arterial cannulation (DAC) compared with right axillary cannulation (RAC) for ATAAD.MethodsFrom January 2016 to December 2018, 431 ATAAD patients were enrolled in the study. Patients were divided into DAC group (n = 341) and RAC group (n = 90). Propensity score matching analysis was performed to compare the early and mid-term outcomes between these two groups. To confirm the organ protection effect by DAC, intraoperative blood gas results and cardiopulmonary bypass parameters were compared between the two groups.ResultsDemographics and preoperative comorbidities were comparable between two groups, while patients in DAC group were younger than RAC group (51.55 ± 13.21 vs. 56.07 ± 12.16 years, P < 0.001). DAC had a higher incidence of limb malperfusion (18.2% vs. 10.0%, P = 0.063) and lower incidence of coronary malperfusion (5.3% vs. 12.2%, P = 0.019). No significant difference in cardiopulmonary bypass and cross-clamp time was found between the two groups. The in-hospital mortality was 13.5% (58/431), while there was no difference between the two groups (13.5% vs. 13.3%; P = 0.969). Patients who underwent DAC had higher incidence of postoperative stroke (5.9% vs. 0%, P = 0.019) and lower incidence of postoperative acute kidney injury (AKI) (24.7% vs. 40.3%; P = 0.015). During a mean follow-up period of 31.8 (interquartile range, 25–45) months, the overall survival was 81.5% for DAC group and 78.0% for RAC group (P = 0.560). Intraoperative blood gas results and cardiopulmonary bypass parameters showed that DAC group had more intraoperative urine output volume than RAC group (P = 0.05), and the time of cooling (P = 0.04) and rewarming (P = 0.04) were shorter in DAC group.ConclusionsDAC will not increase the surgical risks compared to RAC, but could reduce the incidence of postoperative AKI which may be benefit for renal protection.

Femoral versus axillary cannulation in acute type A aortic dissections: A meta-analysis.

There has been a growing interest in antegrade cannulation techniques in type A aortic dissection surgery. Axillary cannulation has previously been reported to provide better outcomes in terms of short-term mortality and neurological event. Consensus regarding the best cannulation strategy still remains controversial. The MEDLINE and EMBASE databases were conducted up until October 3, 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random-effects modelling and the I2 -test for heterogeneity. Fourteen retrospective observational studies were included, enrolling a total of 2621 patients. There were a total of 2621 patients (1327 axillary cannulation and 874 femoral cannulation). Axillary cannulation was associated with reduced short term mortality (pooled odds ratio [OR] = +0.42, 95% confidence interval [CI] = +0.25 to +0.70; p = .0009) compared to femoral cannulation. Axillary cannulation was also associated with a lower incidence of neurological events (pooled OR = +0.63, 95% CI = +0.42 to +0.94; p = .02). Our meta-analyses suggests that axillary cannulation has superior outcomes in terms of mortality and stroke following emergency surgery for type A aortic dissection. However, the lack of high quality randomized controlled trials does not make this recommendation generalisable to all units.

Direct Axillary Artery Cannulation for Type A Dissection and Impact of Dissected Innominate Artery

BackgroundThis study assessed the safety of direct axillary artery (AX) cannulation for acute type A dissection (ATAD) repair, including the impact of innominate artery dissection (IAD). MethodsOf 281 consecutive patients who underwent ATAD repair from 2007 to 2020, preoperative computed tomography was available in 200 (IAD, n = 101; non-IAD, n = 99). IAD with compromised true lumen was defined as dissection in which the false lumen was greater than 50% of the IA diameter (n = 75 of 101). ResultsAX cannulation was attempted in 188 patients (94.0%), with a 1.6% vascular injury rate (3 patients), comprising bypass to the distal AX in 2 patients and local dissection in 1 patient. Deep hypothermic circulatory arrest was used for the distal repair in 89.5% of patients. Right AX cannulation was used in 80.2% of patients with IAD and in 88.9% without IAD (P = .075). Patients with IAD had more cerebral (21.8% vs 5.1%, P = .001) and arm malperfsion (11.9% vs 4.0%, P = .075). Operative death and stroke were comparable between non-IAD (8.1% vs 7.9%, P = 1.00) and IAD (4.0% vs 5.3%, P = .689) groups. The right AX was successfully used in 77.3% of IAD patients with a compromised true lumen, with comparable hospital outcomes to noncompromised IAD patients. Upper extremity malperfusion, multiorgan malperfusion, low ejection fraction, and female sex were predictors for noncannulation of the right AX. ConclusionsRoutine direct AX cannulation strategy is safe in ATAD repair. Right AX cannulation can be used in most patients with IAD, even with a compromised true lumen, with low mortality, stroke, and vascular injury rates.

Direct true lumen versus conventional cannulation for acute type-A aortic dissection.

Acute type-A aortic dissection is a surgical emergency and has a high rate of short-term mortality. Aortic dissection is highly under-reported in Pakistan. With the technological developments in its management, arterial cannulation technique of direct true lumen cannulation has emerged with improved outcomes. We aimed to compare the mortality and morbidity outcomes between direct true lumen and conventional cannulation techniques for arterial access in patients with acute type- A aortic dissection under a single-centre retrospective review from 2007 to 2017. Mean age of the participants was 43.3±11.6 vs 45±12.4 years with males being dominant in both groups. Frequency of overall morbidity was high in conventional cannulation group (Group-B), though it did not attain statistical significance, (p>0.999). Mortality rate was also high in Group-B (10% vs 30%), (p=0.582). Direct true lumen cannulation is an equally reliable option for establishing cardiopulmonary bypass due to reduced mortality and morbidity and may be given preference when dissection is extending into femoral and innominate arteries.

The direct aortic cannulation for acute type A aortic dissection

The direct aortic cannulation for acute type A aortic dissection

Ascending aortic cannulation in acute type A aortic dissection: a frightening but lifesaving procedure

Different cannulation sites (e.g., femoral artery, axillary artery, left ventricular apex, and ascending aorta) and perfusion techniques (anterograde or retrograde) have been used for treating acute type A aortic dissection. The patient’s pathology and status determine the cannulation site. We present our experience with ascending aortic cannulation for acute type A aortic dissection.

EComment. Extended utilization of axillary cannulation as arterial access for cardiopulmonary bypass

In cardiovascular practice today, the axillary artery is one of the best alternative cannulation sites in acute type A aortic dissection [1]. It provides potential benefits such as antegrade perfusion of the aorta, low risk of false lumen perfusion in aortic dissection, and the possibility of antegrade cerebral perfusion during aortic arch repair. Indications of axillary cannulation also includes porcelain aorta, ascending aorta and aortic arch aneurysm, coronary artery disease associated with severely atherosclerotic ascending aorta, extracorporeal membrane oxygenation support, and complex redo cardiac surgery such as aortic regurgitation after previous ascending aortic replacement and pseudo-aneurysm after Bentall operation. We read with great interest the article by Fong and associates [2], regarding liberal use of axillary artery cannulation for cardiopulmonary bypass in aortic and complex cardiac surgical patients. We mostly agree with their considerations. However, we believe that some aspects of the article require further comment. Direct or graft-interposed axillary cannulation still remains a controversial issue among the cardiovascular surgeons. We routinely prefer direct right axillary cannulation in acute type A aortic dissections in our institute [3]. In our practice, there were no major complications related to this cannulation technique. In our opinion, direct axillary cannulation is not more traumatic, is less time-consuming, and less haemorrhagic during the operation than the graft interposition. Axillary cannulation is not always free from risk. Complications related to axillary cannulation are becoming associated with increased use of this technique [4]. These include ipsilateral brachial plexus injury resulting in hand weakness and numbness, axillary artery thrombosis, lymphocele requiring aspiration, vascular compromise, compartment syndrome involving the forearm, postoperative bleeding or local wound infection. Acute intraoperative aortic dissection due to the arterial cannulation into the axillary artery is a rare and devastating complication [5]. It is believed to be due to an intimal flap occurring during cannula insertion. As a strategy to prevent these complications, the arterial cannula should not be advanced too much during the right axillary cannulation. Forced cannulation should also be absolutely avoided. It may cause arterial injury or obstruct the right carotid artery. In our experience, a 20F or 22F flexible cannula was gently advanced 3-4 cm into the axillary artery. In strategic planning for arterial cannulation, transoesophageal echocardiography (TEE) guidance is useful to ensure correct placement of the cannula. An angiograhic, TEE or ultrasound examination plays an important role in preoperative evaluation including aortic branch vessels Axillary cannulation is an attractive and useful approach with an extended utilization, and may be safely used in aortic surgery and complex cardiac procedures including redo surgery. Conflict of interest: none declared.

Ascending Aortic Cannulation in Acute Type A Dissection Repair

Femoral and axillary cannulation for arterial inflow in acute type A aortic dissection are the most commonly used cannulation strategies in current practice. More recently, our group and others have successfully used a central cannulation technique with excellent results. Although this approach has been described, specific technical details have not been clearly defined. In addition, the ideal anatomic characteristics of different types of aortic dissections amenable to central cannulation have not been delineated. The purpose of this brief communication is to describe the technical and procedural details specific to cannulation of the dissected ascending aorta and to propose a classification scheme of ascending aortic dissection anatomy based on difficulty of central cannulation.

A safe and rapid direct true lumen cannulation for acute type A aortic dissection

For the repair of acute type A aortic dissection (AADA), the optimal site of arterial cannulation remains controversial. We herein describe and investigate a technique for direct true lumen cannulation in patients with AADA. Between January 2011 and April 2012, 176 consecutive patients underwent emergency surgery for repair of AADA using the direct true lumen cannulation. Using this method, following temporary circulatory arrest, the dissected ascending aortic wall is incised transversely and the true lumen is identified. An aortic cannula is inserted into the true lumen directly, and the ascending aorta is snared tightly. The manipulation was performed within 30s in all patients. There were no technical problems with this method. The mean operative time, cardiopulmonary bypass time, cross-clamp time, and the circulatory arrest time were 241±79, 158±85, 123±97 and 58±39min, respectively. There were no permanent neurological disorders following surgery. Seven patients (4.0%) experienced temporary neurological disorders. Twenty-four patients (14%) died in the hospital from several complications unrelated to technical problems of direct true lumen cannulation. Antegrade perfusion can be established safely and easily using the direct true lumen cannulation, which may be a promising standard arterial cannulation technique for the repair of AADA.

An unusual complication related to axillary artery cannulation for acute type A aortic dissection repair

An unusual complication related to axillary artery cannulation for acute type A aortic dissection repair

Transatrial cannulation for acute type A dissection

Transatrial cannulation for acute type A dissection

Arterial cannulation for acute type A aortic dissection

Arterial cannulation for acute type A aortic dissection

Reevaluation of Direct True Lumen Cannulation in Surgery for Acute Type A Aortic Dissection

The optimal mode of arterial cannulation in acute type A aortic dissection is controversial. We retrospectively investigated our experience with direct true lumen cannulation as an alternative to standard cannulation procedures. From April 2004 to August 2007, 29 patients (20 men, 9 women; mean age of 63.2 +/- 12.6 years) underwent emergency operation for acute type A aortic dissection with direct true lumen cannulation. After venous drainage into the venous reservoir, the ascending aorta was completely transected in the region between the sinotubular junction and innominate artery. After visual and digital identification of the true lumen, the arterial cannula was directly inserted into the true lumen and secured with a ligature. Mean aortic cross-clamp time was 77.4 +/- 28.3 minutes, and hypothermic circulatory arrest for the distal anastomosis was 10.4 +/- 11.0 minutes. All patients survived the surgical procedure. No surgical problems were observed by applying this strategy. Mean intensive care unit stay was 4.0 +/- 3.5 days. Postoperative mean ventilation time was 43.3 +/- 41.3 hours. One patient had a prolonged postoperative course and required permanent ventilation. Two patients required temporary hemofiltration. Neurologic disorders occurred in 6 patients: 2 had severe cerebral hypoxia, and 4 had temporary hemiplegia under good regression. All patients were alive at discharge. Direct true lumen cannulation is a promising surgical strategy for emergency operations in type A aortic dissection. It is a simple, quick, and safe method to provide antegrade flow through the true aortic lumen.

Ascending aorta cannulation in acute type A aortic dissection

Antegrade perfusion for type A acute aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via ascending aorta may improve the surgical results of type A dissections, especially in the situations of hemodynamic instability. Thus, we evaluated the efficacy of use of the dissected ascending aorta as an alternative arterial inflow. Between 2002 and 2006, 32 patients underwent prosthetic graft replacement of the ascending aorta or hemiarch for acute type A aortic dissection. The ascending aorta was routinely cannulated, in addition to the femoral artery, with a heparin-coating flexible cannula for arterial inflow, using Seldinger technique, and by epiaortic ultrasonographic guidance (n=6). Antegrade systemic perfusion via ascending aorta was performed. Ascending aorta cannulation was safely performed in all cases. There was no malperfusion or thromboembolism due to ascending aorta cannulation. Cardiopulmonary bypass was established within 30 min after skin incision. There was one in-hospital death due to duodenal bleeding (1/32=3.1%), two cases of cerebral infarction (2/32=6.3%), and one case of pulmonary embolism. Twenty-nine patients (29/32=90.6%) were discharged in New York Heart Association class I and have been followed up uneventfully for a mean of 17 months. Antegrade perfusion via the ascending aorta was successfully performed with low mortality and morbidity. With ultrasound-guided Seldinger technique, ascending aorta cannulation has a potential to be a simple and safe option that enables rapid establishment of antegrade systemic perfusion in patients with acute type A aortic dissection.

Which is more appropriate for right axillary artery cannulation in acute type A aortic dissection — directly or with graft?

Which is more appropriate for right axillary artery cannulation in acute type A aortic dissection — directly or with graft?