Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery? Free

Summary

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery?’ Altogether 393 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Femoral artery cannulation has the highest rate of mortality, stroke rate and other complications including retrograde cerebral embolization, organ malperfusion and perfusion of the false lumen. Five out of 14 papers were found to be reporting in favour of axillary (or subclavian) artery cannulation over femoral artery cannulation. In a total of 1829 patients evaluated in these studies, 1068 patients demonstrated a significantly lower complication rate with axillary artery cannulation than femoral artery cannulation. Some of the larger studies showed femoral artery cannulation has higher mortality and stroke rates ranging from 6.5% to 40% and 3% to 17%, respectively. Meanwhile, mortality and stroke rates were ranging from 3% to 8.6% and 1.75% to 4%, respectively, in the favour of axillary artery cannulation. A total of seven studies evaluated direct aortic cannulation for the establishment of cardiopulmonary bypass (CPB). They demonstrated mortality and stroke rates from 0% to 15% and 3.8% to 21%, respectively. Central cannulation has promising results with a lower mortality rate but a higher stroke rate. Direct cannulation of the true lumen is a promising method for quick and easy establishment of CPB. Axillary artery cannulation with a side graft, although it takes more time to construct, is proven to be safe and straightforward, with fewer local and systemic complications including lower mortality and neurological complications.

1. Introduction

A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

2. Three-part question

In [patients, undergoing surgery, for acute type A aortic dissection] is [central ascending aorta cannulation] better than [peripheral arterial cannulation] to reduce [morbidity, stroke rate and mortality]?

3. Clinical scenario

You are planning an emergency repair of a type A aortic dissection. Your usual technique is to use femoral arterial cannulation, but the last time you used this technique the patient suffered a postoperative stroke. You wonder whether and alternative method of cannulation would reduce the chance of this complication.

4. Search strategy

The search was performed using http://highwire.stanford.edu interface. The search terms used were: acute type A aortic dissection, axillary, femoral and aortic cannulation.

5. Search outcome

Three hundred and ninety-three papers were found using the reported search. From these 14 papers were identified that provided the best evidence to answer the question. These are presented in Table 1 .

6. Results

Recently, Kamiya et al. [2] analysed the results of 235 patients undergoing surgery for acute type A aortic dissection using direct ascending aortic cannulation and percutaneous femoral artery cannulation. These authors showed that ascending aortic cannulation has lower mortality than femoral artery cannulation. However, there were no significant differences in the incidence of stroke and long-term survival between these two groups.

Khaladj and co-workers [3] concluded ascending Ao cannulation using the Seldinger technique was a safe, quick and easy to establish. In a review of 122 patients, mortality at 30 days was 15%, which matches statistics reported in other studies. They observed 12% stroke rate and 17% temporary neurological dysfunction.

Reece et al. [4] have shown 0% mortality and 21% stroke rate in ascending aortic cannulation using the Seldinger technique, while there was a 17% mortality and a 28% stroke rate in the peripheral artery cannulation group (femoral and axillary). Furthermore, they suggest that the site of cannulation should be tailored to both the specifics of dissection and the patient. If a clot is present in the false lumen, an alternative cannulation technique in the ascending aorta should be considered.

Reuthebuch and co-authors [5] compared two peripheral cannulations, subclavian artery vs. femoral artery, in 122 patients undergoing surgery for acute type A aortic dissection. They have shown subclavian artery cannulation has lower mortality (8.6% vs. 23.3%), lower prolonged postoperative neurological dysfunction (1.75% vs. 17.4%) and lower renal failure (11% vs. 23%). Extension of dissection to the cerebral vessels, ascending aorta, and infrarenal abdominal aorta were higher in femoral group.

Sabik et al. [6] specified and studied the effect of axillary artery cannulation with a side graft (SG) and without a SG in 391 patients. In their study, the overall mortality was 8%. They concluded that axillary artery cannulation with or without SG has similar mortality, but axillary cannulation with SG can decrease local complication (e.g. brachial plexus injury) up to 0.5% vs. 2.8% and risk of aortic dissection to 0% vs. 1.4%. Overall, axillary artery cannulation can decrease organ malperfusion, retrograde embolization and other complications related to peripheral cannulation.

From the Cleveland Clinic, Svensson and co-workers [7] reported results of a large cohort of 1336 patients, undergoing complex cardiac surgeries using different cannulation techniques like aortic (n=471), axillary with SG (Ax+SG) (n=299), axillary with no SG (Ax no SG) (n=167), femoral (n=374) and innominate artery (n=24). Among all these cannulation techniques, Ax+SG has the lowest mortality (7.0%) and stroke (4.0%) rate. Interestingly, stroke rate is higher (7.8%) in the Ax no SG group. Although, they studied other patients not only those undergoing surgery for type A aortic dissection, they showed axillary artery cannulation to be the preferred method of cannulation for complex aortic surgery and re-operations.

Chiappini et al. [8] reviewed the result of 487 patients treated for acute type A aortic dissection in Italy and The Netherlands. Most of the surgeries (98.2%) were performed using femoral artery cannulation for the establishment of the cardiopulmonary bypass (CPB). In their patients, mortality rate was 22% and stroke rate was 18.2%.

Fusco et al. [9] retrospectively studied 86 patients treated for acute aortic dissection. Seventy-nine of them were cannulated through the femoral artery. Fifteen patients died, out of which, only two had documented femoral artery cannulation as a related cause of death and one had an aortic cannulation related death. They concluded that femoral artery cannulation was not the main cause of death and stroke.

Unlike others, Conzelmann et al. [10] first performed venous drainage and then opened the ascending aorta followed by direct true lumen cannulation during type A aortic dissection surgery. They observed 0% mortality and 21% neurological complications. They proved that technical simplicity and the quick establishment of an additional arterial access was a major advantage when performing surgery of aortic dissections.

Moizumi et al. [11] compared the results of surgery for acute type A aortic dissection using the femoral and axillary arteries in a retrospective study of 106 patients. In univariate and multivariate analysis, absence of axillary artery perfusion is shown to be an independent intraoperative predictor of hospital death. Mortality rate was 7.2% in the axillary group and 30% in the femoral group, proving axillary artery cannulation to be an effective method of cannulation in improving the results of surgery for acute type A aortic dissection.

Inoue et al. [12] conducted a study on direct ascending aortic cannulation using the Seldinger technique, guided by epiaortic ultrasound, in 32 patients undergoing surgery for acute type A aortic dissection. They established CPB using femoral artery cannulation before switching to ascending aortic cannulation. A mortality rate of 3.1% and neurological complication of 6.3% was found. Although, no complication related to the extension of the dissection, false lumen or malperfusion occurred in their series; this technique is time consuming and has the potential risk of retrograde embolization.

In 2007, Nouraei et al. [13] retrospectively reviewed the results of 49 patients operated on for acute type A aortic dissection using femoral and subclavian artery cannulation over a five-year period. In their series of cases, the subclavian cannulation group had a lower mortality rate (10%), while univariate analysis showed femoral cannulation as a significant predictor of neurological deficit and mortality.

Analysing a large cohort of 869 patients with complex aortic pathologies, Etz et al. [14] have shown that the use of axillary artery cannulation for CPB lowers the mortality and stroke rate compared to direct ascending aorta and femoral artery cannulation.

Budde et al. [15] used axillary cannulation to establish CPB in 61 patients undergoing elective and emergent surgery for acute ascending aortic syndrome. There were no significant difference in postoperative temporary neurological dysfunction and mortality in elective and emergent groups: 4.9% vs. 5% and 7.3% vs. 10%, respectively. They claimed that the use of axillary artery cannulation in emergent cases was appropriate, efficacious and safe in an elective setting.

7. Clinical bottom line

Several cannulation techniques have been proposed to establish CPB for surgery of acute type A aortic dissection. In spite of concern over the fragility of vessels and distal embolization during ascending aortic cannulation of a dissected aorta, it has promising results with a lower mortality rate, a lower incidence of malperfusion but has a higher stroke rate. A total of seven studies evaluated direct aortic cannulation for the establishment of CPB. They demonstrated mortality and stroke rates from 0% to 15% and 3.8% to 21%, respectively. Direct cannulation of the true lumen is an emerging method for quick and easy establishment of CPB. Although, femoral artery cannulation is the standard option in many centres, it has the highest rate of mortality, stroke rate and other complications including retrograde cerebral embolization, organ malperfusion and perfusion of the false lumen. Five out of 14 papers were found to report in favour of axillary (or subclavian) artery cannulation over femoral artery cannulation. In a total of 1829 patients evaluated in these studies, 1068 patients demonstrated a significantly lower complication rate with axillary artery cannulation than femoral artery cannulation. Some of the larger studies showed that femoral artery cannulation has higher mortality and stroke rates ranging from 6.5% to 40% and 3% to 17%, respectively. Meanwhile, mortality and stroke rates ranged from 3% to 8.6% and 1.75% to 4%, respectively, in favour of axillary artery cannulation. Axillary artery cannulation emerges as an elegant method for CPB. It provides continuous unilateral blood flow without interruption. Although it takes more time to construct, axillary artery with a SG is proven to be safe and straightforward, with fewer local and systemic complications, lower mortality and neurological complications.

References