Innominate Artery Cannulation Research Articles

Exploring Differences in Surgical Outcomes Depending on the Arterial Cannulation Strategy for Acute Type A Aortic Dissection: A Single-Center Study.

Type A aortic dissection (AD) and intramural hematoma (IMH) are critical medical conditions. Emergency surgery is typically performed under cardiopulmonary bypass immediately after diagnosis, which involves lowering the body temperature to induce total circulatory arrest. Selection of the arterial cannulation site is a critical consideration in cardiac surgery and becomes more challenging in patients with AD. This study explored the strengths and weaknesses of different cannulation methods by comparing each cannulation strategy and analyzing the reasons for patients' outcomes, especially mortality and cerebrovascular accidents (CVAs). This retrospective study reviewed the medical records of patients who underwent surgery for type A AD or IMH between 2008 and 2023, using the moderate hypothermic circulatory arrest approach at a single center. Among the 146 patients reviewed, 32 underwent antegrade cannulation via axillary, innominate artery, aortic, or transapical cannulation, while 114 underwent retrograde cannulation via the femoral artery. The analysis of surgical outcomes revealed a significant difference in the total surgical time, with 356 minutes for antegrade and 443 minutes for retrograde cannulation (p<0.001). The mean length of stay in the intensive care unit was significantly longer in the retrograde group (5±16 days) than in the antegrade group (3±5 days, p=0.013). Nevertheless, no significant difference was found between the groups in the 30-day mortality or postoperative CVA rates (p=0.2 and p=0.7, respectively). Surgeons should consider an appropriate cannulation strategy for each patient instead of adhering strictly to a specific approach in AD surgery.

Systematic Innominate Artery Cannulation Strategy in Acute Type A Aortic Dissection: Better Perfusion, Better Results.

(1) Background: Arterial cannulation in type A acute aortic dissection (TAAAD) is still subject to debate. We describe a systematic approach of using the innominate artery for arterial perfusion (2) Methods: The hospital records of 110 consecutive patients with acute TAAAD operated on between January 2014 and December 2022 were retrospectively analyzed. The effect of the cannulation site on early and late mortality, as well as on cardio-pulmonary perfusion indices (lactate and base excess levels, and cooling and rewarming speed) were investigated. (3) Results: There was a significant difference in early mortality (8.82% vs. 40.79%, p < 0.01) but no difference in long-term survival beyond the first 30 days. Using the innominate artery enabled the use of approximately 20% higher CPB flows (2.73 ± 0.1 vs. 2.42 ± 0.06 L/min/m2 BSA, p < 0.01), which resulted in more rapid cooling (1.89 ± 0.77 vs. 3.13 ± 1.62 min/°C/m2 BSA, p < 0.01), rewarming (2.84 ± 1.36 vs. 4.22 ± 2.23, p < 0.01), lower mean base excess levels during CPB (-5.01 ± 2.99 mEq/L vs. -6.66 ± 3.37 mEq/L, p = 0.01) and lower lactate levels at the end of the procedure (4.02 ± 2.48 mmol/L vs. 6.63 ± 4.17 mmol/L, p < 0.01). Postoperative permanent neurologic insult (3.12% vs. 20%, p = 0.02) and acute kidney injury (3.12% vs. 32.81%, p < 0.01) were significantly reduced. (4) Conclusions: systematic use of the innominate artery enables better perfusion and superior results in TAAAD repair.

Innominate Artery Cannulation for Proximal Aortic Surgery.

The aim of this study was to evaluate the efficacy and safety of innominate artery cannulation strategy with side-graft technique in proximal aortic pathologies. A total of 70 patients underwent innominate artery cannulation with a side graft for surgery on the proximal aorta from 2012 to 2020. There were 46 men and 24 women with an average age of 56±13 years. The indications for surgery were type A aortic dissection in 17 patients (24.3%), aortic aneurysm in 52 patients (74.3%), and ascending aorta pseudoaneurysm in one patient (1.4%). The innominate artery was free of disease in all patients. Hypothermic circulatory arrest with antegrade cerebral perfusion was utilized in 60 patients (85.7%). Three patients had previous sternotomy (4.2%). The most common surgical procedure was ascending aorta with hemiarch replacement in 34 patients (48.5%). The mean cardiac ischemia and cardiopulmonary bypass times were 116+46 minutes and 164+56 minutes, respectively. Mean antegrade cerebral perfusion time was 27+14 minutes. The patients were cooled between 22°C and 30°C during surgery. Thirty-day mortality rate was 7.1% (five patients). One patient (1.4%) had stroke, one patient (1.4%) had temporary neurologic deficit, and eight patients (11.4%) had confusion and agitation that resolved completely in all cases. There was no local complication or arterial injury. Cannulation of the innominate artery with side graft is safe and effective for both cardiopulmonary bypass and antegrade cerebral perfusion. This technique provides satisfactory neurologic outcomes for proximal aortic surgery.

Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection

Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula. Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality. Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen. Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.

Abstract 9865: Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE Cardiolink-3 Randomized Trial

Introduction: Our objective was to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging (DWI) on brain MRI after aortic arch surgery. Methods: This was an imaging sub-analysis of the ACE CardioLink-3 randomized controlled trial which compared the safety and efficacy of innominate vs axillary artery cannulation during elective proximal aortic arch surgery. All participants in the trial underwent pre- and post-operative MRI. New ischemic lesions were defined as lesions on post-operative DWI that were not visible on the pre-operative DWI. Results: Of 102 patients who underwent surgery, 71 (70%) had new ischemic lesions on DWI and the total lesion number across all participants was 391. The average lesion number in patients with at least one ischemic lesion was 5.5±4.9, and were similar in the right (3.3±2.7) or left (3.6±2.8) hemispheres (p=0.49). The most common lesion patterns were single or multiple cortical infarcts. Half of the lesions (n=183, 47%) were in the middle cerebral artery territory, while 24% were in the infratentorium. 42% of patients had lesions distributed in both anterior and posterior circulation, 21% in anterior circulation only, and 7% in posterior circulation only. Besides, 20% had lesions in watershed areas. There were no differences in distribution between patients in the innominate vs axillary artery cannulation groups. In multivariable regression models, more severe white matter hyperintensity on pre-operative MRI (odds ratio per 1-score increase of Fazekas scale 1.80; p=0.02) and lower nadir temperature during operation (odds ratio per 1°C decrease, 1.14; p=0.05) were associated with having any new ischemic lesion, while older age (risk ratio per 1-year increase 1.02; p=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06; p=0.06) were associated with higher lesion numbers. Conclusion: In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and mostly identified as scattered cortical infarcts in the middle cerebral artery territory. Advanced age, underlying small vessel disease, and lower nadir temperature during operation were risk factors of presence and burden of new ischemic lesions after surgery.

Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE CardioLink-3 Randomized Trial.

to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging on brain magnetic resonance imaging after aortic arch surgery. This preplanned secondary analysis of the randomized, controlled ACE (Aortic Surgery Cerebral Protection Evaluation) CardioLink-3 trial compared the safety and efficacy of innominate versus axillary artery cannulation during elective proximal aortic arch surgery. Participants underwent pre and postoperative magnetic resonance imaging. New ischemic lesions were defined as lesions visible on postoperative, but not preoperative diffusion weighted imaging. Of the 111 trial participants, 102 had complete magnetic resonance imaging data. A total of 391 new ischemic lesions were observed on diffusion-weighted imaging in 71 (70%) patients. The average number of lesions in patients with ischemic lesion were 5.5±4.9 with comparable numbers in the right (2.9±2.0) and left (3.0±2.3) hemispheres (P=0.49). Half the new lesions were in the middle cerebral artery territory; 63% of the cohort had ischemic lesions in the anterior circulation, 49% in the posterior circulation, 42% in both, and 20% in watershed areas. A probability mask of all diffusion-weighted imaging lesions revealed that the cerebellum was commonly involved. More severe white matter hyperintensity on preoperative magnetic resonance imaging (odds ratio, 1.80 [95% CI, 1.10-2.95]; P=0.02) and lower nadir nasopharyngeal temperature during surgery (odds ratio per 1°C decrease, 1.15 [95% CI, 1.00-1.32]; P=0.05) were associated with the presentation of new ischemic lesion; older age (risk ratio per 1-year increase, 1.02 [95% CI, 1.00-1.04]; P=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06 [95% CI, 1.00-1.14]; P=0.06) were associated with greater number of lesions. In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and predominantly involved the middle cerebral artery territory or cerebellum. Underlying small vessel disease, lower temperature nadir during surgery, and advanced age were risk factors for perioperative ischemic lesions. URL: https://www. gov; Unique identifier: NCT02554032.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Innominate artery patency after direct cannulation in neonates.

ObjectiveThe study objective was to determine the short-term incidence of innominate artery stenosis for neonates who underwent direct innominate artery cannulation during the Norwood procedure.MethodsThis is a retrospective, single-institution review of 92 patients who underwent the Norwood procedure with direct innominate artery cannulation from 2006 to 2017. The primary outcome was angiographic evidence of patency at pre-Glenn cardiac catheterization. Patient characteristics, intraoperative surgical and hemodynamic measurements, and postoperative neurologic findings were recorded.ResultsAt a median age of 5.0 days, 92 neonates underwent the Norwood procedure with direct innominate artery cannulation. These patients underwent cardiac catheterization at a median of 3.0 months after the index operation. In 5 of 92 patients with catheterization images available for review, there was angiographic evidence of mild innominate artery stenosis, and none had moderate or severe stenosis. Review of follow-up records did not reveal evidence of clinically significant stenosis or innominate artery reintervention.ConclusionsIn neonates undergoing the Norwood procedure with direct innominate cannulation, innominate artery stenosis was uncommon and clinically significant stenosis did not occur.

Direct Innominate Artery Cannulation versus Side Graft for Selective Antegrade Cerebral Perfusion during Aortic Hemiarch Replacement.

Background Selective antegrade cerebral perfusion (SACP) has become our preferred method for cerebral protection during open arch cases. While the initial approach involved sewing a graft to the innominate artery as the arterial cannulation site, our access strategy has since evolved to central aortic cannulation with use of a percutaneous cannula in the innominate for SACP. We hypothesized that SACP delivered via direct innominate cannulation using a 12- or 14-Fr cannula results in equivalent outcomes to cases utilizing a side graft. Methods This was a single-center, retrospective analysis of 211 adult patients who underwent elective hemiarch replacement using hypothermic circulatory arrest with SACP via the innominate artery between 2012 and 2020. Urgent and emergent cases were excluded. Results A side graft sutured to the innominate was utilized in 81% ( n = 171) of patients, while direct innominate artery cannulation was performed in 19% ( n = 40) of patients. Baseline patient characteristics were similar between groups aside from a higher baseline creatinine in the direct cannulation group (1.3 vs. 0.9, p = 0.032). Patients undergoing direct cannulation demonstrated shorter cardiopulmonary bypass time (132.7 vs. 154.9 minutes, p = 0.020) and shorter circulatory arrest time (8.1 vs. 10.9 minutes, p = 0.004). Nadir bladder temperature did not significantly differ between groups (27.2°C for side graft vs. 27.6°C for direct cannulation, p = 0.088). There were no significant differences in postoperative outcomes. Conclusion Direct cannulation of the innominate artery with a 12- or 14-Fr cannula for SACP during hemiarch replacement is a safe alternative to using a sutured side graft. While cardiopulmonary bypass and circulatory arrest times appear improved, this is likely attributable to accumulation of experience and proficiency in technique. However, direct innominate artery cannulation may facilitate quicker completion of these procedures by eliminating the time necessary to suture a graft to the innominate artery.

Computational numerical analysis of different cannulation methods during cardiopulmonary bypass of type A aortic dissection model based on computational fluid dynamics.

BackgroundThe aim of the present study was to use a numerical simulation based on computational fluid dynamics (CFD) to analyze the difference of different cannulation methods on hemodynamics characteristic in a type A aortic dissection (TAAD) model.MethodsA finite-element analysis based on the CFD model of a TAAD patient was used, and axillary artery cannulation (AAC), innominate artery cannulation (IAC), and femoral artery cannulation (FAC) were analyzed under different situations, including a cardiac output (CO) of 2.5 L/min and cardiopulmonary bypass (CPB) of 2.5 L/min (partial CPB before cross-clamping aorta, defined as condition A), and a CO of 0 L/min and CPB of 5 L/min (aortic cross-clamping phase, defined as condition B). The insertion of an 8-mm cannula into the different models was simulated. Hemodynamic characteristics, including wall shear stress, wall stress, blood flow, and velocity were analyzed.ResultsIn condition A, the total flow of branches of the aortic arch was 2,009.5 mL/min (AAC), 1,855.47 mL/min (IAC), and 1,648.03 mL/min (FAC). All cannulation methods improved left renal blood perfusion. However, in relation to blood flow in the right renal artery, FAC showed the highest blood flow (105 mL/min). The results in condition B were similar to those of condition A. The velocity, shear stress, and stress of entry tear via AAC and IAC decreased in condition B compared with condition A. The velocity, shear stress, stress of tear via AAC was lower than that of IAC.ConclusionsDifferent cannulation modes have an effect on the hemodynamic characteristic of the tear, but this effect is related to different states of CPB. AAC was found to superior to IAC, especially in reducing velocity, stress, and shear stress of site of tear. However, IAC and AAC are more conductive to blood supply than FAC in branch vessels of the aortic arch without being affected by the CPB state.

A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery

BackgroundCerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy. ObjectiveTo compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery. MethodsThis randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, ClinicalTrials.gov Identifier: NCT02554032), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke. ResultsOne hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups. Conclusionsdiffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.

Abstract 16765: Sustained Total All-Region Perfusion During the Norwood Operation is Associated With Improved Post-Operative Recovery

Introduction: We developed a technique for Stage 1 “Norwood” reconstruction with continuous perfusion of the head, heart, and lower body at mild hypothermia, deemed Sustained Total All-Region (STAR) perfusion. Hypothesis: We hypothesized that STAR perfusion would shorten cardiopulmonary bypass and procedural times and expedite post-operative recovery, due to lack of cooling and re-warming and decreased total body ischemia. Methods: Between 2012-2019, 65 infants underwent Norwood reconstruction at our institution. Those who underwent prior pulmonary artery banding were excluded, yielding a cohort of 51 infants who underwent primary Norwood reconstruction. Outcomes for patients who underwent Norwood reconstruction using STAR perfusion (n=21) were compared to those who underwent Norwood reconstruction with conventional techniques using regional cerebral perfusion only (n=30). STAR perfusion was performed with innominate artery cannulation as well as olive tip cannulas inserted into the opened descending aorta and native aortic root to provide continuous perfusion of the head, heart, and lower body throughout the procedure (Figure), under mild hypothermia (32-34°C). Results: Norwood reconstruction with STAR perfusion was associated with shorter median CPB times vs. conventional perfusion techniques (161 vs. 226 mins,p&lt;0.0001) and elimination of myocardial ischemia (0 vs. 90 minutes cross-clamp time,p&lt;0.0001). Total operative time was reduced by over 3 hours (319 vs 514 mins,p&lt;0.0001), likely in part due to improved post-bypass coagulopathy. Improvements in post-operative recovery were noted with STAR perfusion, including more rapid normalization of serum lactate (19.3 vs. 26.5 hours, p=0.0009), lower peak serum lactate (8.6 vs.10 mmol/dL, p=0.04) and fewer days to chest closure (3 vs. 5 days, p=0.04). Survival to hospital discharge (95% vs 83%, p=0.38) was similar between groups. Conclusions: Norwood reconstruction with STAR perfusion is a safe technique that eliminates ischemic time to the heart and lower body and allows for the procedure to be performed at warmer temperatures. We found evidence of reduced CPB and operative times, as well as improved hemostasis, end-organ function, and post-operative recovery with this technique.

Innominate Artery Cannulation during Redo Sternotomy for Patients with a Right Aortic Arch with Mirror Image Branching

Innominate Artery Cannulation during Redo Sternotomy for Patients with a Right Aortic Arch with Mirror Image Branching

The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection

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.

A simple method to establish antegrade cerebral perfusion during hemiarch reconstruction.

ObjectiveWe describe a novel and safe technique using a 12F–14F pediatric arterial cannula to establish unilateral, selective, antegrade cerebral perfusion (ACP) during open hemiarch reconstruction.MethodsBetween January 2015 and September 2018, 42 patients underwent elective aortic aneurysm repair requiring an open distal anastomosis and at least a hemiarch replacement via hypothermic circulatory arrest by 2 surgeons. All distal reconstructions were performed at moderate hypothermia (22°C–26°C) with direct cannulation of the innominate artery (IA) using a pediatric arterial cannula to allow ACP at 10–15 mL/kg/min. Data were collected by retrospective chart review.ResultsThirty-one of the 42 patients (74%) were male. The mean patient age was 65 ± 13 years, and the mean body surface area was 2.1 ± 0.3 m2. Proximal repairs included a modified Bentall with a valve-graft composite (n = 17), valve-sparing root replacement (n = 2), and aortic valve replacement (n = 15). Perioperative mortality was 2% (n = 1), and the incidence of stroke was 0%. The mean lowest core body temperature reached during circulatory arrest was 23.8 ± 2.7°C with a mean ACP time of 21.8 ± 3.6 minutes. The mean aortic cross-clamp and cardiopulmonary bypass times were 160.6 ± 55.5 minutes and 204.7 ± 57.5 minutes, respectively. There were no cases of IA injury.ConclusionsDirect IA cannulation with a pediatric arterial cannula is a safe and efficient method to allow ACP in aortic surgery requiring hypothermic circulatory arrest and may circumvent the potential complications of axillary cannulation.

P5602Comparison of innominate vs axillary artery cannulation for cerebral protection on neurocognitive outcomes in aortic surgery: a pre-specified analysis of the ACE CardioLink-3 randomised trial

Abstract Background Success after aortic surgery depends on avoidance of neurocognitive dysfunction, thus novel adjuncts to proximal aortic surgery must be evaluated for efficacy of cerebral protection during circulatory arrest. We report the primary neurocognitive results from the ACE CardioLink-3 randomised controlled trial comparing innominate to axillary artery cannulation for cerebral protection (NCT02554032). Methods The primary safety endpoint was the proportion of patients with new radiologically severe ischaemic cerebral lesions found on post-operative versus pre-operative diffusion weighted magnetic resonance imaging (DW-MRI). Neurocognitive outcomes were assessed using the Mini-Mental State Exam (MMSE), and the Montreal Cognitive Assessment (MoCA). Continuous and binary outcomes were analysed using ANCOVA (controlling for baseline score) and chi-square/Fisher's exact tests. Results Of the 111 patients randomised, 102 patients were included in the primary safety per-protocol analysis. The primary safety outcome (significant new ischaemic lesions on DW-MRI) occurred in 34% in the innominate group and 38.8% in the axillary group (OR 0.81; 0.41 to 1.60; P=0.0009 for non-inferiority). Rates of post-operative stroke/transient ischaemic attack, seizure, delirium, and encephalopathy were similar between groups. The rate of patients with a post-operative MoCA score less than 26 was 44.9% and 39.1% in the innominate and axillary groups respectively (P=0.807). A post-operative MMSE score of less than 24 was observed in 2% vs. 6.5% of the patients in the innominate and axillary groups respectively (P=0.866). A &gt;1-point decrease in the MoCA score from pre-operatively to post-operatively was seen in 32.7% and 34.8% in the innominate and axillary groups respectively (P=0.962). A &gt;1-point decrease in the MMSE score from pre-to post-operative was observed in 20.4% in the innominate artery group compared with 30.4% in the axillary group (P=0.346). Conclusion Post-operative neurocognitive dysfunction and DW-MRI incidence of severe ischaemic lesions did not differ in patients randomised to innominate artery cannulation vs, conventional axillary artery cannulation, though the burden of new severe ischaemic lesions is high in both groups.

Direct Arterial Cannulation Allows Easy and Safe Continuous Selective Cerebral Perfusion During Repair of Interrupted Aortic Arch Even for Low Birth Weight Neonates.

To review the outcomes of direct innominate artery cannulation for continuous cerebral perfusion used for repair of interrupted aortic arch (IAA) in a consecutive cohort of neonates regardless of weight. Between September 1999 and April 2016, forty-four children with IAA (18 type A and 26 type B) underwent repair using continuous, hypothermic (18°C) low-flow cerebral perfusion via direct innominate artery cannulation. Associated cardiac lesions were truncus arteriosus (TA; 5), ventricular septal defect (VSD; 30), transposition of the great arteries (TGA; 1), unbalanced atrioventricular septal defect (1), double-inlet left ventricle (1), double-outlet right ventricle (3), and aortopulmonary window (APW; 5). Truncus arteriosus, single VSD, TGA, and APW were corrected while the other patients were palliated. Age at the time of surgery was 7 days (4-120 days) and weight 3.1 kg (2.1-5.8 kg). Selective cerebral perfusion was maintained in all patients. During the selective cerebral perfusion, perfusion flow rate was maintained at 30 mL/kg/min. Aortic cross-clamp time, low-flow, and total cardiopulmonary bypass time were 63 (40-116), 28 (17-41), and 108 (80-217) minutes, respectively. There were no deaths nor clinical evidence of neurological injury. Postoperative ventilation time, length of intensive care unit, and hospital stay were 3 (2-14), 5 (3-21), and 13 (6-27) days, respectively. Follow-up, complete at 84 months (24-221), revealed no late clinically evident neurologic sequelae nor innominate artery complications. Direct innominate arterial cannulation with continuous selective cerebral perfusion can be safely applied for repair of IAA even in low birth weight neonates. It is technically simple and associated with excellent clinical outcomes.

Proximal arterial cannulation in thoracic aortic surgery-Literature review.

Surgery on thoracic aorta is complex with a number of approaches being required depending on the pathology and anatomy that is specific to each patient and therefore, careful planning is required to ensure successful outcomes. Among the key factors that determine a satisfactory and safe operation is the choice of arterial cannulation site to establish cardiopulmonary bypass and deliver brain protection adequately. Direct proximal aortic cannulation is the gold-standard method for elective aortic root surgery and traditionally femoral arterial cannulation has been used in complex aortic surgeries such as redo or acute pathologies; however, axillary and innominate artery (IA) cannulation has evolved dramatically and several centers are currently using proximal cannulation sites as the default cannulation choice in elective and emergency settings of complex thoracic aortic surgeries. The evidence behind cannulating the IA is growing; however, it is yet to be well established through large studies or trial to confirm its superiority to other methods of central cannulation techniques.

In thoracic aortic surgery, is innominate artery cannulation a safe and effective alternative to axillary artery cannulation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in a patient undergoing thoracic aortic surgery, is innominate artery cannulation superior to axillary artery cannulation in terms of postoperative outcomes? Five hundred and thirty-one papers were found using the reported search strategy, of which 5 represented the best evidence to answer the clinical question. A total of 1338 participants were included across the 5 studies. Seven hundred and twenty-two patients were cannulated via the axillary artery and 616 were cannulated via the innominate artery. The included 5 studies were 2 prospective observational cohorts, 2 retrospective case-series analysis and a single-blinded randomized trial. Thirty-day or in-hospital mortality rates were reported in all 5 studies. There were no significant differences in mortality with innominate artery cannulation compared to axillary artery cannulation (P > 0.05), with slightly lower mortality rates in 2 studies, slightly higher mortality rates in 2 and equal in 1 study. Though statistical significance was not demonstrated (P > 0.05), a stroke occurred slightly less frequently in patients receiving innominate artery cannulation compared to axillary artery cannulation in 3 of the 4 studies. Innominate artery cannulation is non-inferior to axillary artery cannulation for thoracic aortic surgery, with a similar level of neuroprotection and is not associated with increased levels of mortality.

Innominate vs. Axillary Artery Cannulation in Aortic Surgery: a Systematic Review and Meta-Analysis.

ObjectiveTo investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery.MethodsA comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017.ResultsOnly three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups.ConclusionThere is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.