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Ann Thorac Surg 2004;78:1274-1284
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Does the Arterial Cannulation Site for Circulatory Arrest Influence Stroke Risk?

^a Departments of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA,
^b Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication April 20, 2004.

^* Address reprint requests to Dr Svensson, The Cleveland Clinic Foundation, 9500 Euclid Ave/Desk F24, Cleveland, OH, USA 44195
svenssl{at}ccf.org

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.

	Abstract

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
BACKGROUND: We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest.

METHODS: Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression.

RESULTS: Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs).

CONCLUSIONS: Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

	Introduction

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
The safety of complex cardiac and cardioaortic operations has improved as a consequence of progress in the intraoperative management of patients [1–17]. Although subclavian or axillary arteries have been used for arterial inflow for various operations [18–21], Sabik and colleagues [22] popularized their use for complex cardiac operations. Subsequently, Baribeau and colleagues [23] described the use of these arteries for arch atheroma and arteriosclerotic operations. In 1995, L.G.S. began to use this peripheral cannulation strategy with hypothermic circulatory arrest and antegrade brain perfusion and found it to be a safe approach for aortic arch operations; it resulted in a stroke risk of less than 2% [11, 13, 24]. These smaller series, however, did not demonstrate a benefit for the peripheral cannulation strategy over the use of other sites of arterial inflow, such as the femoral artery or aorta [12, 25].

The primary purpose of this study, therefore, was to determine in a large series of operations performed with circulatory arrest whether the use of axillary and subclavian artery inflow was beneficial, particularly in reducing the risk of stroke. Second, we sought to identify other risk factors for stroke and hospital mortality.

	Patients and Methods

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
Between January 1993 and May 2003, 1,352 operations for complex cardiac and cardioaortic problems were performed with circulatory arrest on 1,318 patients (32 had 2 operations, and 1 had 3). Excluded from the study were patients who had coronary artery bypass grafting or aortic valve replacement alone. These operations were identified from the Cardiovascular Information Registry, an ongoing registry of clinical and outcome data that is updated concurrently with patient care. Data in this registry have been approved for use in research by the institutional review board.

	Cannulation Sites

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
A total of 1,336 operations involved the use of a single arterial inflow cannulation site, and these formed the basis for our comparisons. (In 16 operations, 2 sites were used—in 12, aortic and femoral; in 2, femoral and subclavian; in 1, both subclavians; and in 1, innominate and aortic. These patients were not included in the comparative analyses.) Single cannulation sites were aorta (n = 471), femoral (n = 374), axillary (n = 258; 166 with side graft), subclavian (n = 208; 133 with side graft), external iliac (n = 1), and innominate (n = 24).

The site of attaching the 8- or 10-mm tube graft to the subclavian or axillary arteries differed slightly among surgeons [10, 13, 22, 26]; some preferred to use the subclavian artery, defined as that part of the artery proximal to the outer edge of the first rib, and others preferred the axillary artery, defined as that part beyond the outer edge of the first rib. The difference between these sites is that for subclavian artery cannulation, the subclavius muscle was cut, part of the muscle was excised, and the artery was mobilized and encircled proximal to the medial nerve branch of the pectoral muscle. For axillary artery cannulation and attachment of a side graft, the artery lateral to the nerve branch was used. This segment is slightly smaller, and there are more arterial branches. For the purposes of this study, these 2 groups were combined because there was little difference between the 2 cannulation sites.

This study focused, then, on outcome after 166 plus 133 (n = 299) axillary and subclavian artery cannulations with a side graft (Ax plus SG) compared with direct arterial cannulation of these arteries without a side graft (Ax no SG) and of other sites. Patient characteristics overall and within the direct and Ax plus SG groups are shown in Table 1.

	Operations and Other Support Techniques

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

In all but 7 patients, the operation included replacement of the ascending aorta, arch, or descending aorta, alone or in combination (Table 1). The ascending aorta was replaced in 1,160 patients (87%), the arch in 415 (31%), and the descending aorta in 248 (19%), including 94 elephant trunk procedures. Ax plus SG was used in 84 (34%) versus 215 of the 1,086 (20%) who did not have descending aorta repair (p < 0.0001). For reoperations in patients who had a previous ascending aortic graft, generally only an aortic arch procedure was performed.

Retrograde brain perfusion (RBP) was used in 933 patients (70%): 225 (75%) with Ax plus SG compared with 708 (68%) with direct cannulation. Antegrade brain perfusion combined with Ax plus SG was used selectively in the latter part of the study for patients who required total aortic arch replacement, typically with an elephant trunk procedure. These patients are also part of an ongoing randomized study by L.G.S. of brain protection methods for total aortic arch replacement. Thus, only 34 patients had antegrade brain perfusion; none had a stroke.

Surgical methods and the preferred brain protection protocol have been described previously [9–12, 14, 22, 27]. Briefly, patients were cooled to a core temperature of less than 20°C, and circulatory arrest was instituted when there was no evidence of brain activity, whenever feasible. The use and type of brain perfusion during circulatory arrest were at the surgeon's discretion. Antegrade perfusion was performed by perfusing through the subclavian side graft while occluding the innominate artery with a balloon catheter and also occluding the left subclavian artery [11]. The alpha-stat method of pH control and a membrane oxygenator were used for cardiopulmonary bypass.

	Outcome

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
The 2 primary measures of outcome were stroke and mortality. Stroke was defined as a physician-diagnosed new postoperative neurologic deficit lasting more than 72 hours, generally confirmed by computed tomography of the head, and considered to be a cerebral vascular accident. Mortality was defined as in-hospital death from any cause. In addition, other postoperative complications were tabulated, including bleeding, defined as a return to the operating room for excessive postoperative bleeding or tamponade; renal failure, defined as the requirement for dialysis; respiratory failure, defined as reintubation or the occurrence of acute respiratory distress syndrome; and sepsis, defined as any positive postoperative blood culture.

	Data Analysis

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
General
The ² test was used for comparing categorical variables when the smallest number of individuals in a category was greater than 5, and Fisher's exact test was used otherwise. Continuous variables were compared by using the t test or Wilcoxon's rank-sum test if distribution of the variable was skewed.

Strategy
The primary analyses were comparisons of hospital outcome after operations in which Ax plus SG had been used versus those of various direct cannulation strategies. Because patient, pathologic, and other operative characteristics differed among patients in whom these various cannulation techniques were used, with Ax plus SG used in generally higher-risk patients (Appendix 1), we applied the propensity-based pairwise matching technique to obtain the fairest risk-adjusted comparison of outcome [28, 29]. Secondary analyses were performed to identify incremental risk factors associated with stroke and hospital mortality.

Comparison Using Propensity Methods
Using preoperative variables (Tables 1, 2) and cardiopulmonary bypass time, we identified factors associated with receiving Ax plus SG versus direct cannulation (all sites, aorta, femoral or iliac, and Ax no SG) with multivariable logistic regression. Initially a parsimonious multivariable model was developed (Appendix 1) for each comparison by using bootstrap bagging, as previously detailed, and a P value criterion of 0.05 [30, 31]. Having established parsimonious models, we added other variables representing groups of patient and cardioaortic factors that might be related to unrecorded selection factors (saturated model) [28]. A propensity score was calculated for each patient by solving the saturated model for the probability of having Ax plus SG.

Risk Factors for Stroke and Hspital Mortality
Multivariable logistic regression analysis was used to identify incremental risk factors for stroke and hospital mortality. A sequential analysis strategy was used by first analyzing only patient variables, then adding operative procedure variables, and finally adding perfusion support variables. Variable selection used bootstrap bagging for each of the models in the sequence, as described previously for developing the parsimonious models for Ax plus SG. In addition, when analyzing perfusion support variables, we included interactions between each aortic pathologic feature (Table 1) and the use of RBP, each site of cannulation and the use of RBP, and 3-way interactions between use of Ax plus SG, RBP, and aortic pathologic features.

Presentation
Because transformation of the scale of continuous variables was often necessary to meet statistical model assumptions, the results of logistic models are presented with their coefficients rather than less interpretable odds ratios. Uncertainty is expressed by confidence limits (CL) equivalent to ± 1 standard error (68%).

	Results

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
Stroke
Stroke occurred in 81 of the 1,336 patients (6.1%; CL, 5.4% to 6.8%). Among 299 patients who had Ax plus SG, stroke occurred in 12 (4.0%), versus 69 (6.7%) among 1,037 who had direct cannulation (Tables 3, 4).

Secondary multivariable analysis of stroke identified as incremental risk factors history of hypertension, history of renal failure, ischemic heart disease, emergency operation (generally for acute aortic dissection), and aortic arteriosclerotic disease (Table 5). As operative variables were added to the analysis, repair of the descending aorta only, mitral valve replacement, and direct cannulation, rather than just Ax plus SG, emerged as risk factors. A protective effect of RBP, or of the combination of this with Ax plus SG, was not identified with reliability, although the combination was statistically significant at p less than 0.05 in 40% of the bootstrap analyses. See Appendix 2 for the multivariate analysis of factors associated with the use of RBP and the biases involved. Table 6 shows unadjusted outcomes for selected variables.

Secondary multivariate analysis of hospital mortality identified as incremental risk factors preoperative renal and hepatic failure and need for emergency operation (Table 7). An earlier date of operation was identified as a risk factor when only patient variables were analyzed; it was supplanted by descending aortic procedure when procedure variables were added and by longer aortic clamp time, longer circulatory arrest time, and, with high reliability (86% of bootstrap samples), RBP as a protective factor. See Table 6 for outcome according to selected variables.

	Comment

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
Comparison of Cannulation Strategies
The arterial inflow site for cardiopulmonary bypass grafting has varied over the last 5 decades. Initially, femoral or subclavian arteries were used, but distal ascending aortic inflow then became the preferred site. Subsequently, direct femoral artery cannulation was advocated for most ascending aortic and aortic arch procedures and also for some reoperations [16]. This approach, however, was associated with a greater risk of stroke in some patient groups, particularly those with concurrent descending, thoracoabdominal, or abdominal aortic aneurysms. This was probably because atheroma, clot, or other atheroembolic material in these segments is pumped from these aneurysms or dissection sites retrograde to the brain [12, 16].

Recently, the theoretical advantages of using the subclavian or axillary artery site for inflow for complex cardiac and cardioaortic operations have become apparent [2, 12, 13, 22–27]. These possible advantages include less likelihood of stroke from embolic material, less likely malperfusion with aortic dissection, less disruption of atheroma or calcified plaques, and the ability to administer antegrade brain perfusion. No large study, however, has examined whether this strategy is superior to other cannulation sites. For example, a previous report found similar stroke occurrence among different arterial cannulation sites [12]. Of note, the sites were carefully chosen on the basis of the potential for atheroembolic material being present in the descending or thoracoabdominal aorta. As a result, the occurrence of stroke was low (< 2%), and the statistical power to show a difference according to site was limited. In this study, Ax plus SG was used for complex cases, and although there was only probable statistical difference on unadjusted analysis, when comparisons accounted for greater severity of comorbid factors and operative complexity, Ax plus SG was associated with a lower risk that was unlikely to be due to chance.

When using the subclavian or axillary artery for inflow, it became clear to early adopters [13, 22, 24] that the direct cannulation was associated with a greater risk of local complications, including dissection of the artery, inadequate flow, abutment of the cannula tip against the carotid artery wall, and tears that were difficult to repair because of fragile and often traumatized arterial tissue. Thus, arterial inflow was switched to a side graft sewn to the vessel, and at the end of the operation, a delicate and sometimes difficult repair of the artery was not required; instead, the side graft could simply be oversewn and tied off or clipped.

Secondary Findings
Of interest, RBP was associated with lower hospital mortality and possibly a lower risk of stroke. The role of RBP continues to be debated. It may be that this technique is associated with a greater risk of subtle neurocognitive changes, such as temporary depression and temporary neurologic deficits [1, 5, 7]. Although no strokes occurred in our previously reported randomized study of either retrograde or antegrade brain perfusion (through the subclavian artery with a side graft), both were associated with a greater risk of neurocognitive deficits compared with hypothermic circulatory arrest alone when used for short periods [11]. Whether this holds true for prolonged periods of circulatory arrest is unclear. Theoretically, on the basis of our previous research in which the risk of stroke increased after 40 minutes of circulatory arrest, circulatory arrest exceeding 30 to 40 minutes may require some form of brain perfusion [16].

However, the risk of respiratory failure with Ax plus SG was surprising. It may have occurred because in the Ax plus SG group, fewer strokes occurred, and so patients were less prone to pulmonary complications, such as reintubation because of problems in airway protection.

Limitations
The cannulation site was not chosen at random, but in part by surgeon preference and in part by actual or perceived necessity. Therefore, we used propensity matching in an attempt to make fair comparisons. Because of disparate propensity scores and limited patients to match, there were many unmatched cases in some comparisons; such comparisons are valid for the matched group but may ignore important differences among patients for whom a systematic strategy seemed to have been used. Propensity matching also does not balance unrecorded factors.

Likewise, the secondary multivariate analyses were limited by the number of events, and this reduced their sensitivity in identifying possibly subtle factors. However, a sequential analysis approach and bootstrap bagging were used to identify the factors most reliably associated with outcome.

Finally, this was a study in a single institution whose surgical composition has changed. This generated heterogeneity, which we have exploited to make comparisons, but it also resulted in unaccounted-for heterogeneity that may have influenced outcomes.

Clinical Inferences
On the basis of our current understanding and this study, we use Ax plus SG as our preferred method of arterial inflow for complex cardiac procedures, such as difficult reoperations, including minimally invasive reoperations on the aorta or aortic valve [27]; arteriosclerosis or calcification of the aorta [14, 17, 33]; aortic arch operations; circulatory arrest; and left thoracotomy for descending or thoracoabdominal repairs with involvement of the aortic arch [26]. We add retrograde or antegrade brain perfusion during circulatory arrest when we expect prolonged circulatory arrest, as discussed previously, particularly for elephant trunk procedures [34]. We believe that Ax plus SG has contributed to the evolution of safer operations for complex cardiac and cardioaortic operations.

	Appendix 1

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
Variables Associated With Use of Side Graft Versus Methods of Direct Cannulation (multivariable logistic regression models)

Variable Coefficient ± SE p Value Ax + SG vs direct cannulation (all sites) Lower NYHA classa –0.083 ± 0.016 <0.0001 Peripheral vascular disease 0.62 ± 0.14 <0.0001 Lower hematocritb –0.91 ± 0.31 0.003 Higher BUNc –0.46 ± 0.14 0.002 Longer CPB timed 0.62 ± 0.19 0.002 Intercept –2.8 ± 1.04 ... Ax + SG vs direct aortic cannulation Lower NYHA classa –0.059 ± 0.019 0.002 Peripheral vascular disease 0.41 ± 0.17 0.01 Lower hematocritb –0.98 ± 0.35 0.005 Higher BUNc –0.402 ± 0.16 0.01 Longer CPB timed 0.48 ± 0.26 0.06 Hypertension 0.36 ± 0.19 0.07 Less mitral regurgitation –0.29 ± 0.079 0.0003 Intercept –1.6 ± 1.3 ... Ax + SG vs direct femoral/iliac cannulation Lower NYHA classa –0.087 ± 0.019 <0.0001 Peripheral vascular disease 1.2 ± 0.19 <0.0001 Higher BUNc –0.75 ± 0.19 <0.0001 Longer CPB timed 1.3 ± 0.25 <0.0001 Lower bilirubine –0.77 ± 0.19 <0.0001 Intercept –5.9 ± 1.3 ... Ax + SG vs direct axillary/subclavian cannulation Lower NYHA classa –0.076 ± 0.021 0.0002 Higher BUNc –0.72 ± 0.21 0.0007 No ventricular arrhythmia –0.68 ± 0.31 0.03 Lower bilirubine –0.59 ± 0.22 0.007 Intercept 1.7 ± 0.304

Ax + SG = axillary or subclavian cannulation with a side graft;

BUN = blood urea nitrogen;

CPB = cardiopulmonary bypass;

NYHA = New York Heart Association;

SE = standard error.

^a (New York Heart Association functional class)² transformation.

^b (Hematocrit/40)² transformation.

^c (20/blood urea nitrogen) inverse transformation.

^d Log(cardiopulmonary bypass time) logarithmic transformation.

^e Log(bilirubin) logarithmic transformation.

	Appendix 2

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 
Correlates of Retrograde Brain Perfusion

Using the multivariable methods and sequential approach described under "Data Analysis," we identified factors related to the probability of having retrograde brain perfusion (RBP).

The factors associated with a greater probability of RBP are given in Table 1. RBP was less likely to be used in reoperations, in patients with renal failure, in those having descending thoracic aorta repair (particularly if that was the only aortic repair), and in those with greater functional impairment from ischemic heart disease. It was more likely to be used in patients with aortic aneurysms and more recently. It was more likely to be used in cases with longer circulatory arrest duration and when axillary or subclavian peripheral cannulation was used with or without a side graft; in contrast, it was less likely to be used when femoral artery cannulation was used.

These selection factors reflect the evolution of techniques over time, differing surgeon preferences, preoperative assessment of the duration of circulatory arrest needed to complete the operation, and use of alternative techniques to protect the brain, such as antegrade perfusion.

Discussion

DR NICHOLAS T. KOUCHOUKOS (St. Louis, MO): Dr Pairolero, Dr Murray, ladies and gentlemen. Using propensity matching and multivariate logistic regression analyses, Dr Svensson and his colleagues have retrospectively analyzed a large series of more than 1,300 patients undergoing complex adult cardiac surgical procedures involving the use of circulatory arrest, to determine whether axillary or subclavian cannulation with a side graft reduces the risk of stroke and mortality when compared with direct cannulation of the axillary artery, the aorta, or the femoral/iliac or innominate arteries.

On the basis of their analyses, they conclude that the technique does reduce the risk of stroke and that it is their cannulation site of choice for these complex operations. Their data also suggest that the risk of hospital death is lower with this technique when compared with femoral or iliac artery cannulation.

Of interest, the unadjusted and propensity-matched comparisons of axillary or subclavian artery cannulation with a graft against each of the other sites of direct cannulation separately did not demonstrate a difference that was not due to chance with a p value criterion of 0.05. Only when the axillary or subclavian artery with graft group was compared with all of the direct cannulation sites combined was a p value of 0.05 attained, and only with propensity matching.

In the multivariate analysis that incorporated patient, procedural, and support variables and techniques, direct cannulation emerged as a predictor of stroke, but only at the 0.07 level and with only moderate reliability. It is also of interest that the highest stroke rate, 7.8%, occurred among the patients who had direct cannulation of the axillary or subclavian artery without the use of a side graft.

Intuitively, and on the basis of earlier publications from the Cleveland Clinic and elsewhere, use of the axillary or subclavian artery with a graft technique would seem to offer distinct advantages over direct cannulation of the aorta or more peripheral sites for complex procedures involving circulatory arrest.

The data from this study strongly suggest but do not conclusively prove that this is the case in terms of reduced stroke and mortality rates. The failure to prove this hypothesis with high reliability in this study relates in part to the substantial heterogeneity of the patient population studied and the biases and preferences of the individual surgeons, which resulted in a failure to match many of the patients in the propensity analyses. This limitation is acknowledged by the authors in the article. It also relates to a low prevalence of stroke and death. Furthermore, as Dr Blackstone, a coauthor of this article, has taught us in previous publications, propensity matching does not balance factors that may be important in affecting outcome but that were not analyzed.

Despite these concerns, I concur with Dr Svensson and his colleagues that the axillary or subclavian artery with a graft technique should be the preferred method of cannulation for complex aortic procedures and reoperations that require circulatory arrest. We have also found it of value in patients with coronary artery or valvular heart disease who have severe arteriosclerosis of the ascending aorta and aortic arch. However, the absolute value of this technique will likely be proven only in a large randomized trial.

I have several questions for Dr Svensson. The highest stroke rate occurred among the patients who had direct cannulation of the axillary or subclavian artery. Do you have an explanation for this, and is this technique currently used at the Cleveland Clinic?

Did you encounter any complications with the side graft technique, and are there any contraindications to its use?

On the basis of this experience, is there any role for femoral or iliac artery cannulation in current practice for these complex procedures?

The lowest prevalence of postoperative respiratory failure occurred among the patients with the axillary or subclavian artery with graft technique. Can this be attributed to this technique?

Finally, temporary neurologic dysfunction after circulatory arrest occurs with equal or greater frequency than stroke. Did you examine the presence of this complication in the various cannulation groups?

This is a very important article. I congratulate the authors and appreciate the opportunity to discuss it. Thank you.

DR SVENSSON: Thank you, Dr Kouchoukos, for those insightful and gracious comments. To answer your questions about direct cannulation, we do not use direct cannulation at our institution any longer, and the reason for that is that Dr Sabik has an article coming out showing that the local complication rate was higher with this technique.

As far as the risk of stroke with this technique, I think there is a greater risk because of reaming out of any potential atheroma in the artery or damaging the intima when one puts the cannula into the subclavian artery and feeds it up. We have seen cases in which the cannula has also obstructed the carotid artery when it has been inserted too far. That is usually reflected as a difficulty with perfusion. The flow rates are generally also lower with direct cannulation.

As far as complications and contraindications with the use of a side graft, we have occasionally seen that where the subclavian artery was stenosed either proximally or distally, this resulted in problems of adequate flow. However, I should point out that with a side graft, at the end of a long operation it is considerably easier to just oversew that graft rather than to repair a subclavian or axillary artery. Often there is intimal damage, and it can be a very delicate procedure, often requiring a vein patch if there are problems.

As far as contraindications, I have come across 4 patients who have had acute dissections in which the dissection had extended down into the subclavian artery, and for various reasons in some of those patients I went ahead and still used the axillary artery; 2 of those patients had a stroke. Whether this was due to this or not is uncertain, but occasionally this a problem. As you know, having used it for arteriosclerotic aortas, it is rare to find atheroma there, but occasionally one does find atheroma, and then one has to think about other options. Clearly, if on preoperative studies the innominate or subclavian artery is stenotic, we do not use it.

As far as use of the femoral artery nowadays, we usually do not use the femoral artery any longer, even though the axillary artery takes a bit longer to prepare. Occasionally in patients with Marfan syndrome, in whom it is less likely that there is any atheroma, and there is no dissection, and when you think you might later want to come back to a virgin subclavian axillary artery, we do not use the subclavian artery. We have, however, done some eight subclavian artery recannulations of the side graft or artery without too much difficulty.

As far as the explanation for lower respiratory failure complications in the axillary with side graft group, I am not sure I can explain that. It is something we found, and I don't have a good reason for that. Clearly, we accounted for the date of surgery in this series, so I do not think that it is related to improved technology. I do not know of anything different that we do as far as, for example, use of steroids or filtration of the blood in this group of patients. There may be subtle differences in intraoperative and postoperative management among surgeons. Also, it may have been because patients had fewer strokes and, therefore, fewer respiratory problems such as reintubation.

As far as the softer criteria of temporary neurologic dysfunction, in this series we were not able to analyze confusion and that type of problem initially after surgery, but our criteria for stroke were very broad and included all notable neurologic events. We have not noted the 19% incidence of temporary neurologic dysfunction reported from other institutions. There may be several reasons for this, including pump setup, amount of cooling, and pump time. As in previous studies, pump time, or, as in this study, the surrogate of cardiac ischemia time, was predictive of complications.

	References

Top Abstract Introduction Patients and Methods Cannulation Sites Operations and Other Support... Outcome Data Analysis Results Comment Appendix 1 Appendix 2 References

 

1. Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg. 2001;72:72–79[Abstract/Free Full Text]
2. Banbury MK, Cosgrove DM III. Arterial cannulation of the innominate artery. Ann Thorac Surg. 2000;69:957[Abstract/Free Full Text]
3. Moon MR, Sundt TM III. Influence of retrograde cerebral perfusion during aortic arch procedures. Ann Thorac Surg. 2002;74:426–431; discussion 31[Abstract/Free Full Text]
4. Coselli JS, LeMaire SA. Experience with retrograde cerebral perfusion during proximal aortic surgery in 290 patients. J Card Surg. 1997;12:322–325[Medline]
5. Ehrlich MP, Hagl C, McCullough JN, et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thorac Cardiovasc Surg. 2001;122:331–338[Abstract/Free Full Text]
6. Westaby S, Katsumata T, Vaccari G. Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome. Eur J Cardiothorac Surg. 1999;15:180–185[Abstract/Free Full Text]
7. Hagl C, Ergin MA, Galla JD, et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg. 2001;121:1107–1121[Abstract/Free Full Text]
8. Di Eusanio M, Wesselink RM, Morshuis WJ, Dossche KM, Schepens MA. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study. J Thorac Cardiovasc Surg. 2003;125:849–854[Abstract/Free Full Text]
9. Lytle BW, McCarthy PM, Meaney KM, Stewart RW, Cosgrove DM III. Systemic hypothermia and circulatory arrest combined with arterial perfusion of the superior vena cava. Effective intraoperative cerebral protection. J Thorac Cardiovasc Surg. 1995;109:738–743[Abstract/Free Full Text]
10. Svensson LG. Progress in ascending and aortic arch surgery: minimally invasive surgery, blood conservation, and neurological deficit prevention. Ann Thorac Surg. 2002;74:S1786–1788 discussion S92–9[Abstract/Free Full Text]
11. Svensson LG, Nadolny EM, Penney DL, et al. Prospective randomized neurocognitive and S-100 study of hypothermic circulatory arrest, retrograde brain perfusion, and antegrade brain perfusion for aortic arch operations. Ann Thorac Surg. 2001;71:1905–1912[Abstract/Free Full Text]
12. Svensson LG, Nadolny EM, Kimmel WA. Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations. Ann Thorac Surg. 2002;74:2040–2046[Abstract/Free Full Text]
13. Svensson LG, Husain A, Penney DL, et al. A prospective randomized study of neurocognitive function and s-100 protein after antegrade or retrograde brain perfusion with hypothermic arrest for aortic surgery. J Thorac Cardiovasc Surg. 2000;119:163–167[Free Full Text]
14. Svensson LG, Sun J, Cruz HA, Shahian DM. Endarterectomy for calcified porcelain aorta associated with aortic valve stenosis. Ann Thorac Surg. 1996;61:149–152[Abstract/Free Full Text]
15. Safi HJ, Brien HW, Winter JN, et al. Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair. Ann Thorac Surg. 1993;56:270–276[Abstract]
16. Svensson LG, Crawford ES, Hess KR, et al. Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg. 1993;106:19–28 discussion 28–31[Abstract]
17. Kouchoukos NT, Wareing TH, Daily BB, Murphy SF. Management of the severely atherosclerotic aorta during cardiac operations. J Card Surg. 1994;9:490–494[Medline]
18. DeBakey ME. Left ventricular bypass pump for cardiac assistanceClinical experience. Am J Cardiol. 1971;27:3–11[Medline]
19. Debakey ME, Henly WS, Cooley DA, Crawford ES, Morris GC Jr, Beall AC Jr. Aneurysms of the aortic arch: factors influencing operative risk. Surg Clin North Am. 1962;42:1543–1554
20. Cohen A, Manion WC, Spencer FC, Czarnecki SW, Debakey ME. Occlusive lesions of the great vessels of the aortic arch: Surgical and pathological aspects. Arch Surg. 1962;84:628–642
21. Creech O Jr, Debakey ME, Mahaffey DE. Total resection of the aortic arch. Surgery. 1956;40:817–830[Medline]
22. Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg. 1995;109:885–890 discussion 90–1[Abstract]
23. Baribeau YR, Westbrook BM, Charlesworth DC, Maloney CT. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg. 1998;66:33–37[Abstract/Free Full Text]
24. Van Arsdell GS, David TE, Butany J. Autopsies in acute type A aortic dissection. Surgical implications. Circulation. 1998;98:II299–302 discussion II302–4
25. Yavuz S, Goncu MT, Turk T. Axillary artery cannulation for arterial inflow in patients with acute dissection of the ascending aorta. Eur J Cardiothorac Surg. 2002;22:313–315[Abstract/Free Full Text]
26. Nadolny EM, Svensson LG. Hypothermic arrest for descending aortic rupture in reoperative patients. Ann Thorac Surg. 2001;71:2027–2030[Abstract/Free Full Text]
27. Svensson LG, Nadolny EM, Kimmel WA. Minimal access aortic surgery including re-operations. Eur J Cardiothorac Surg. 2001;19:30–33[Abstract/Free Full Text]
28. Blackstone EH. Comparing apples and oranges. J Thorac Cardiovasc Surg. 2002;123:8–15[Free Full Text]
29. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70:41–55[Abstract/Free Full Text]
30. Blackstone EH. Breaking down barriers: helpful breakthrough statistical methods you need to understand better. J Thorac Cardiovasc Surg. 2001;122:430–439[Free Full Text]
31. Breiman L. Bagging predictors. Machine Learning. 1996;24:123–140
32. Parsons LS. Reducing bias in a propensity score matched-pair sample using greedy matching techniques. In: Proceedings of the twenty-sixth annual SAS users group international conference. Cary, NC: SAS Institute, 2001:214–26
33. Van Arsdell GS, David TE, Butany J. Commentary on autopsies in acute type A aortic dissection. Surgical implications. Circulation. 1998;98:II299–302 discussion II302–4
34. Svensson LG. Antegrade perfusion during suspended animation? J Thorac Cardiovasc Surg. 2002;124:1068–1070[Free Full Text]

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