| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2004;78:1285-1289
© 2004 The Society of Thoracic Surgeons
a Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
Accepted for publication April 20, 2004.
* Address reprint requests to Dr Elefteriades, 121 FMB, 333 Cedar St, New Haven, CT, USA 06510
john.elefteriades{at}yale.edu
Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.
 |
Abstract |
|---|
 Top Abstract IntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
METHODS: Records of 86 consecutive patients (51 men and 35 women; age, 30 to 86 years; mean, 62 years) undergoing surgical repair for acute type A dissection were reviewed. Cannulation site, specific operative repair, and complications related to cannulation were noted.
RESULTS: Seventy-nine cannulations were performed in the femoral artery (47 left, 23 right, and 9 unspecified), 3 in the axillary artery (1 left and 2 right), and 4 in the ascending aorta or arch. Deep hypothermic arrest was used in 64 operations. Seven involved re-sternotomy. Seventy patients had supracoronary grafts (2 with valve replacement and 10 with valve resuspension), and 16 underwent aortic root replacement. Fourteen patients were in shock from cardiac tamponade. Eighty patients survived the operation, and 71 were hospital survivors. Malperfusion on initiation of cardiopulmonary bypass was noted in 3 patients. In 1, the original cannulation site was the ascending aorta, and the cannula was moved to the femoral artery for correction. In 2, the original cannulation site was the femoral artery, and the cannula was moved to the ascending aorta. Malperfusion on clamping of the aorta or on resumption of aortic flow was noted in no patient. Postoperative ischemia of any vascular bed was noted locally only in 3 (cannulated) lower extremities.
CONCLUSIONS: Straight femoral cannulation for all phases of type A dissection repair is appropriate and yields excellent clinical results. The anticipated malperfusion events are actually rare (2 of 79 with femoral artery cannulation, or 2.5%).
|
Introduction |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
Ascending aortic dissection (Stanford type A or DeBakey type I or II) is a surgical emergency with a high natural morbidity and mortality [2–4]. Its incidence is 5.2 per million per year [5]—twice the rate of ruptured abdominal aortic aneurysm. The treatment has traditionally been repair with right atrial-femoral bypass grafting. However, concern for intraoperative malperfusion syndrome [6–9], reported to be as high as 13% [10], has caused surgeons to search for alternative sites for cannulation [10–17]. Published experience with axillary cannulation for acute ascending dissection is summarized in Table 1. Each series is modest in terms of the number of patients treated with axillary cannulation.
|
The aim of this study was to determine the safety of femoral cannulation for repair of acute type A aortic dissection. This is not intended to be a comparative study of different methods of cannulation, but rather a specific look at a large experience with femoral cannulation, with an eye toward identifying any malperfusion complications of this approach.
|
Material and Methods |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
Our preferred technique involves sequentially
Thus, the femoral cannula is used for the entire procedure, without elective replacement to the constructed graft. We do routinely inspect for malperfusion initially after establishing cardiopulmonary bypass, by measuring the radial artery pressure, checking the head vessels for forward flow by transesophageal echocardiogram, and palpating the aorta. These checks are repeated again after the aorta is cross-clamped.
|
Results |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
Seventy-nine cannulations were performed in the femoral artery (47 left, 23 right, and 9 unspecified), 3 in the axillary artery (1 left and 2 right), and 4 in the ascending aorta or arch. Nonfemoral cannulation sites were chosen because of known ileofemoral disease or disease of the descending or thoracoabdominal aorta. Deep hypothermic arrest was used in 64 operations. Seven operations involved re-sternotomy. Seventy patients had supracoronary grafts with hemiarch repair (2 with aortic valve replacement and 10 with aortic valve resuspension), and 16 underwent aortic root replacement with a composite graft. Eighty patients survived the operation, and 71 of these were hospital survivors.
Malperfusion on initiation of cardiopulmonary bypass was noted in 3 patients (Table 2). In the first, the ascending aorta had been cannulated directly through the dissection. The cannulation site was changed to the right femoral artery, and the case continued. The patient died in the operating room of end-organ ischemia.
|
In the third case, the left femoral artery was used for cannulation. High back pressure was noted after cardiopulmonary bypass was established. The ascending aorta was then cannulated directly, and cardiopulmonary bypass was reestablished. The patient survived the operating room but eventually died from complications of a stroke. Thus, the adverse event rate in patients initially cannulated in the femoral artery was only 2 of 79, or 2.5%. The third malperfusion-type event in this experience occurred after aortic—not femoral—cannulation. All 77 other patients underwent surgical replacement of the aorta with femoral cannulation and perfusion with no perfusion abnormalities.
Malperfusion on clamping of the aorta or on resumption of aortic flow was not seen in any patient. Postoperative ischemia of any vascular bed was noted in only 3 (cannulated) lower extremities. These were all believed to be local phenomena of the lower extremity vascular system, caused by cannulation and suture repair of the femoral arteriotomy. Other postoperative complications are shown in Table 3.
|
|
|
|
Comment |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
We have no quarrel with axillary cannulation for acute type A dissection repair. We believe that the data presented in this study indicate that the traditional approach of femoral cannulation is indeed a safe one, with years upon years of worldwide application. We point out that the total experience recorded in the literature for axillary cannulation for type A repair (Table 1) is rather scant and that the published articles do not confirm the superiority of axillary over femoral cannulation.
We believe strongly in the use of axillary artery cannulation for the repair of arteriosclerotic ascending and arch aneurysms, because these patients often have extensive atheromata that can be embolized to the brain. In contradistinction, it is our experience that patients with acute ascending dissection rarely manifest arteriosclerosis or plaque in the descending (or ascending) aorta. Our experience in this regard is supported by published literature indicating less common arteriosclerosis in dissection patients [18], as well as by studies pointing to a molecular basis for such a trend [19–21]. Of course, some type A patients will on occasion manifest thoracoabdominal arteriosclerosis, which may predispose to retrograde embolization during femoral perfusion. One can point out that in our experience we may have selected such individuals as the few type A patients in whom we did apply axillary cannulation. We see this not as a demerit of the femoral perfusion technique, but rather as a demonstration that clinical judgment and flexibility in the selection of perfusion technique are warranted.
Femoral cannulation continues to be a safe technique for establishing cardiopulmonary bypass for the repair of acute ascending aortic dissections.
|
Discussion |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
DR FUSCO: Thank you for emphasizing the transventricular cannulation alternative. We applied that technique early in our experience, with mixed results. Perfusion was achieved, but we did encounter problems with inadequate sealing of the aortic valve around the cannula and with the large opening remaining in the left ventricular apex after decannulation. Although we did not use the transventricular option in the series of patients reported here, we believe that it is important to be aware of this option.
DR JOHN W. HAMMON (Winston-Salem, NC): I was intrigued by your remark when you said that no cannulation technique can guarantee the absence of malperfusion, so would it not also be very reasonable to monitor patients, such as is being done at the University of Pennsylvania and elsewhere, with electroencephalogram and other techniques to make sure that cerebral perfusion is occurring?
DR FUSCO: We believe that it is crucially important, as you point out, Dr Hammon, to confirm perfusion to the head. We do this by 2 means: palpation of the aortic arch to confirm proper pressurization, and direct visualization of forward flow into the great vessels by transesophageal echocardiography. In terms of confirming the adequacy of deep hypothermia, the electroencephalogram can indeed be useful. Bavaria's data show that after 30 minutes of cooling, approximately 60% of patients achieve electrical silence, and by 45 minutes almost all will be flat-lined. At our institution we simply wait for several minutes' equilibration at a core (urinary bladder) temperature of 18°C.
DR RAUL GARCIA-RINALDI (Mayaguez, Puerto Rico): It has been our impression that the side of the true lumen usually has an absent pulse, whereas the artery that has the best pulse is the one that feeds into the false lumen. Surgeons who do a lot of this type of surgery recommend perfusing into the leg with the worst pulse. Can you comment on that, please?
DR FUSCO: That has not been our approach. We choose the side with the better pulse. If that side is found to be dissected, we go to the contralateral side. If both sides are dissected, we exercise great care to make certain that our cannula is placed into the true lumen. In the current era of 3-dimensional imaging, the computed tomography scan will often point to the better (or, less involved) side for cannulation.
DR SHINICHI TAKAMOTO (Tokyo, Japan): I agree with your conclusion. I am doing this cannulation of the femoral artery for acute dissection. But you mentioned that you anastomose the proximal site first, clamping the ascending aorta in the proximal anastomosis first and subsequently performing the distal anastomosis. I have experienced, after clamping the ascending aorta, that the reentry from the femoral cannulation site is closed because the big entry is closed by the clamping. In such a case, the false lumen is dilated and then causes malperfusion. So I think that in femoral cannulation, the distal anastomosis should be performed during deep hypothermia. What do you think about that?
DR FUSCO: The anatomic pathology of aortic dissection can be very complex 3-dimensionally. Theoretically, clamping the aorta after initiation of perfusion may cause pressurization of the false lumen. We wish to emphasize from this series that malperfusion is extremely rare despite femoral perfusion and clamping of the ascending aorta. Although this is a concern, it simply has not been problematic in our experience. We perform the proximal anastomosis with the clamp on; then we perform an open distal anastomosis with the patient under deep hypothermic circulatory arrest.
DR ADIB H. SABBAGH (Tucson, AZ): Did any of these patients have Marfan's syndrome, and do you change your approach with Marfan's patients?
DR FUSCO: We do not change our approach in Marfan's patients. Approximately 10% of our patients have Marfan's disease. We cannulate femorally and replace the entire ascending aorta and aortic root.
|
References |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  R. S. Bonser, A. M. Ranasinghe, M. Loubani, J. D. Evans, N. M. A. Thalji, J. E. Bachet, T. P. Carrel, M. Czerny, R. Di Bartolomeo, M. Grabenwoger, et al. Evidence, Lack of Evidence, Controversy, and Debate in the Provision and Performance of the Surgery of Acute Type A Aortic Dissection J. Am. Coll. Cardiol., December 6, 2011; 58(24): 2455 - 2474. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Ayyash, M. Tranquilli, and J. A. Elefteriades Femoral artery cannulation for thoracic aortic surgery: Safe under transesophageal echocardiographic control J. Thorac. Cardiovasc. Surg., December 1, 2011; 142(6): 1478 - 1481. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Matalanis, R. S. Koirala, W. Y. Shi, P. A. Hayward, and P. R. McCall Branch-first aortic arch replacement with no circulatory arrest or deep hypothermia J. Thorac. Cardiovasc. Surg., October 1, 2011; 142(4): 809 - 815. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. R. Wong, J. S. Coselli, L. Palmero, J. Bozinovski, S. A. Carter, D. Murariu, and S. A. LeMaire Axillary Artery Cannulation in Surgery for Acute or Subacute Ascending Aortic Dissections Ann. Thorac. Surg., September 1, 2010; 90(3): 731 - 737. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. K. Tiwari, M. Murzi, S. Bevilacqua, and M. Glauber Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery? Interact CardioVasc Thorac Surg, May 1, 2010; 10(5): 797 - 802. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. E. Halkos, F. Kerendi, R. Myung, P. Kilgo, J. D. Puskas, and E. P. Chen Selective antegrade cerebral perfusion via right axillary artery cannulation reduces morbidity and mortality after proximal aortic surgery J. Thorac. Cardiovasc. Surg., November 1, 2009; 138(5): 1081 - 1089. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Kamiya, K. Kallenbach, D. Halmer, M. Ozsoz, K. Ilg, A. Lichtenberg, and M. Karck Comparison of Ascending Aorta Versus Femoral Artery Cannulation for Acute Aortic Dissection Type A Circulation, September 15, 2009; 120(11_suppl_1): S282 - S286. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. O. Conzelmann, N. Kayhan, U. Mehlhorn, E. Weigang, M. Dahm, and C. F. Vahl Reevaluation of Direct True Lumen Cannulation in Surgery for Acute Type A Aortic Dissection Ann. Thorac. Surg., April 1, 2009; 87(4): 1182 - 1186. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. F. Immer, N. B. Aydin, M. Lutolf, E. S. Krahenbuhl, M. Stalder, L. Englberger, F. S. Eckstein, J. Schmidli, and T. P. Carrel Does aortic crossclamping during the cooling phase affect the early clinical outcome of acute type A aortic dissection? J. Thorac. Cardiovasc. Surg., December 1, 2008; 136(6): 1536 - 1540. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Minatoya, H. Ogino, H. Matsuda, and H. Sasaki Rapid and safe establishment of cardiopulmonary bypass in repair of acute aortic dissection: improved results with double cannulation Interact CardioVasc Thorac Surg, December 1, 2008; 7(6): 951 - 953. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. A. Bockeria, A. I. Malashenkov, and S. V. Rychin eComment: Rapid and safe establishment of cardiopulmonary bypass in repair of acute aortic dissection: improved results with double cannulation Interact CardioVasc Thorac Surg, December 1, 2008; 7(6): 953 - 953. [Full Text] [PDF]
|
|
|
|
 |
|
 N. Khaladj, M. Shrestha, S. Peterss, M. Strueber, M. Karck, M. Pichlmaier, A. Haverich, and C. Hagl Ascending aortic cannulation in acute aortic dissection type A: the Hannover experience Eur J Cardiothorac Surg, October 1, 2008; 34(4): 792 - 796. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Shimokawa, S. Takanashi, N. Ozawa, and T. Itoh Management of Intraoperative Malperfusion Syndrome Using Femoral Artery Cannulation for Repair of Acute Type A Aortic Dissection Ann. Thorac. Surg., May 1, 2008; 85(5): 1619 - 1624. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Hata, A. Sezai, T. Niino, M. Yoda, S. Unosawa, N. Furukawa, S. Osaka, T. Murakami, and K. Minami Should emergency surgical intervention be performed for an octogenarian with type A acute aortic dissection? J. Thorac. Cardiovasc. Surg., May 1, 2008; 135(5): 1042 - 1046. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Totaro and V. Argano Innovative technique to treat acute cerebral and peripheral malperfusion during type A aortic dissection repair Interact CardioVasc Thorac Surg, February 1, 2008; 7(1): 133 - 135. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Yavuz What is the best arterial cannulation site in a complicated patient with acute type A aortic dissection? Interact CardioVasc Thorac Surg, February 1, 2008; 7(1): 134 - 135. [Full Text] [PDF]
|
|
|
|
|
|
H. E. Achneck, J. A. Rizzo, M. Tranquilli, and J. A. Elefteriades Safety of Thoracic Aortic Surgery in the Present Era Ann. Thorac. Surg., October 1, 2007; 84(4): 1180 - 1185. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Jakob, K. Tsagakis, A. Szabo, I. Wiese, M. Thielmann, and U. Herold Rapid and safe direct cannulation of the true lumen of the ascending aorta in acute type A aortic dissection J. Thorac. Cardiovasc. Surg., July 1, 2007; 134(1): 244 - 245. [Full Text] [PDF]
|
|
|
|
|
|
A. Zierer, M. R. Moon, S. J. Melby, N. Moazami, J. S. Lawton, N. T. Kouchoukos, M. K. Pasque, and R. J. Damiano Jr Impact of Perfusion Strategy on Neurologic Recovery in Acute Type A Aortic Dissection Ann. Thorac. Surg., June 1, 2007; 83(6): 2122 - 2129. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Inoue, T. Ueda, S. Taguchi, I. Kashima, K. Koizumi, R. Takahashi, and I. Kiso Ascending aorta cannulation in acute type A aortic dissection Eur J Cardiothorac Surg, June 1, 2007; 31(6): 976 - 981. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. G.T. Augoustides Limitations with transapical aortic cannulation in type A aortic dissection: What about aortic regurgitation and cardiopulmonary bypass time? J. Thorac. Cardiovasc. Surg., May 1, 2007; 133(5): 1393 - 1393. [Full Text] [PDF]
|
|
|
|
 |
|
 F. Barili, L. Dainese, G. Polvani, and P. Biglioli Multifactorial Bases of Stroke After Cardiac Surgery Stroke, April 1, 2007; 38(4): 1140 - 1140. [Full Text] [PDF]
|
|
|
|
|
|
H. Gulbins, A. Pritisanac, and J. Ennker Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation? Ann. Thorac. Surg., March 1, 2007; 83(3): 1219 - 1224. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. B. Reece, C. G. Tribble, R. L. Smith, R. R. Singh, B. M. Stiles, B. B. Peeler, J. A. Kern, and I. L. Kron Central cannulation is safe in acute aortic dissection repair J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 428 - 434. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. P. Urbanski, A. Lenos, Y. Lindemann, E. Weigang, M. Zacher, and A. Diegeler Carotid artery cannulation in aortic surgery J. Thorac. Cardiovasc. Surg., December 1, 2006; 132(6): 1398 - 1403. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Wada, S. Yamamoto, J. Honda, A. Hiramoto, H. Wada, and Y. Hosoda Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 369 - 372. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Dhareshwar, A. L. Estrera, P. Achouh, E. E. Porat, and H. J. Safi Cannulation Strategy for Acute Type A Aortic Dissection Ann. Thorac. Surg., June 1, 2006; 81(6): 2340 - 2340. [Full Text] [PDF]
|
|
|
|
|
|
P. P. Urbanski Carotid artery cannulation in acute aortic dissection with malperfusion J. Thorac. Cardiovasc. Surg., June 1, 2006; 131(6): 1398 - 1399. [Full Text] [PDF]
|
|
|
|
|
|
Y. Moizumi Reply Ann. Thorac. Surg., June 1, 2006; 81(6): 2340 - 2341. [Full Text] [PDF]
|
|
|
|
|
|
C. Olsson and S. Thelin Antegrade Cerebral Perfusion With a Simplified Technique: Unilateral Versus Bilateral Perfusion Ann. Thorac. Surg., March 1, 2006; 81(3): 868 - 874. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Santini Survival and quality of life after repair of acute type A aortic dissection in patients aged 75 years and older justify intervention Eur J Cardiothorac Surg, March 1, 2006; 29(3): 386 - 391. [Full Text] [PDF]
|
|
|
|
|
|
J. A. Elefteriades Invited commentary Ann. Thorac. Surg., July 1, 2005; 80(1): 88 - 89. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
