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Ann Thorac Surg 2005;80:77-83
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Axillary Artery Cannulation Improves Operative Results for Acute Type A Aortic Dissection

Division of Cardiovascular Surgery, Sendai City Medical Center, Sendai, Japan

Accepted for publication January 20, 2005.

^_* Address reprint requests to Dr Moizumi, Division of Cardiovascular Surgery, Sendai City Medical Center, 5-22-1 Turugaya, Miyaginoku, Sendai, Miyagiken, Japan (Email: moizumi{at}openhp.or.jp).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: This study was undertaken to identify preoperative and postoperative predictors of hospital death of patients with acute type A aortic dissection.

METHODS: Between May 1,1992, and July 31, 2004, 106 consecutive patients (59 male and 47 female, mean age 62.2 ± 12.1 years) with acute type A aortic dissection underwent surgery with open technique and cerebral protection by antegrade selective cerebral perfusion. The external iliac artery or femoral artery alone was used for arterial cannulation in 37 patients; however, the right axillary artery was cannulated in 69 patients. Univariate analysis of potential risk factors was performed to identify risk factors for hospital death and was followed by multivariate analysis by a stepwise logistic regression model to identify independent risk factors.

RESULTS: Sixteen patients died postoperatively, and the overall hospital mortality rate was 15.1%. Univariate analysis revealed shock (p = 0.020), visceral ischemia (p = 0.007), root replacement (p = 0.041), and absence of axillary artery perfusion (p = 0.003) as significant risk factors for hospital death. Multivariate analysis revealed visceral ischemia (p = 0.0028, odds ratio 18.4) and absence of axillary artery perfusion (p = 0.0014, odds ratio 8.2) as independent preoperative and intraoperative predictors of hospital death.

CONCLUSIONS: Achievement of greater success in the surgical treatment of acute type A dissection will require axillary artery cannulation and measures to prevent visceral malperfusion.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Although acute type A aortic dissection is still one of the most catastrophic and tragic disorders, and its operative mortality is considerably affected by the patient’s preoperative condition, recent advances in operative strategy have led to a remarkable improvement in the early results. Open distal anastomosis with systemic hypothermia, the development of prosthetic materials, and the establishment of cerebral protection by selective cerebral perfusion or retrograde cerebral perfusion, in particular, have doubtless played an indispensable role in achieving the great recent success [1–4].

Many issues regarding the operative results of acute type A aortic dissection have been raised, but previous reports have concerned cases treated at different times during a period in which treatment strategies changed [5]. Since May 1992, however, we have been applying the same strategy when operating on patients with acute type A aortic dissection: resection of primary intimal tear, open distal anastomosis with systemic hypothermia, cerebral protection by selective cerebral perfusion, and reconstruction of the aorta with collagen-pretreated prostheses.

In this study, we retrospectively reviewed 106 cases of acute type A aortic dissection to identify preoperative and intraoperative predictors of hospital death when the above strategy is applied.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Between May 1992 and July 2004, a total of 106 consecutive cases of acute type A aortic dissection were treated surgically in our institution. There were 59 men and 47 women, and their mean age was 62.2 ± 12.1 years (median, 65.0; range, 30 to 84). All but two operations were performed on an emergency basis within 12 hours of admission, and 88% of the patients were operated on within 24 hours after the onset of symptoms. Seventy-seven patients (73%) had one or more dissection-related complications. Fifty-nine patients (56%) were in shock. Seventeen patients (16%) required pericardiocentesis or open drainage in the emergency room or intensive care unit before surgery, and the operations on 5 patients were started during cardiopulmonary resuscitation. Cerebral ischemia developed in 14 patients (7%), and 5 of them were comatose. Visceral ischemia developed in 7 patients (7%), lower limb ischemia in 14 patients (13%), and paraplegia in 2 patients (2%). These preoperative patient characteristics are summarized in Table 1.

Coronary artery bypass graft surgery was the most common concomitant procedure and was performed in 10 (9%) cases. Other concomitant procedures consisted of aortoaxillary artery bypass for upper limb ischemia in 4 patients, femorofemoral artery bypass for lower limb ischemia in 6 patients, and mitral valve replacement in 1 patient (Table 3).

After spontaneous ventricular fibrillation occurred, the ascending aorta was cross-clamped in its midportion, and cardioplegic solution was retrogradely infused (5 to 10 mL/kg) at a coronary sinus pressure below 40 mm Hg. Between 1992 and 1994 we used a crystalloid cardioplegic solution, but since 1995 we have been using a blood cardioplegic solution. The ascending aorta was opened longitudinally and transected circumferentially 1 cm above the coronary ostia, and cardioplegic solution was directly infused (10 to 15 mL/kg) through the nondissected coronary ostium. Additional cardioplegic solution was infused retrogradely (5 mL/kg) and antegradely (10 mL/kg) every 20 minutes throughout the period of cardiac arrest.

The proximal stump of the aorta was reinforced with two layers of Teflon felt strips. Gelatin-resorcin-form-aldehyde (GRF) biologic glue (Laboratoires Cardial, Saint-Etienne, France) was infused into the false lumen or used as an adjunct to surgical repair in 82 cases (77%). Supracoronary anastomosis was performed with 4-0 monofilament continuous sutures and a collagen-pretreated graft with a limb of adequate size. Aortic valve resuspension was achieved by resuspending the valve commissures with Teflon plegdet-support mattress sutures and GRF glue. Root replacement was performed by one of the variants of the Betall procedure. After completion of the proximal repair, circulatory arrest was achieved, and the aortic clamp was released. Selective cerebral perfusion was instituted for brain protection (10 to 15 mL · kg^-1 · min^-1). When the right axillary artery had been used for arterial cannulation, cerebral perfusion was performed through it instead of by innominate artery cannulation.

Two layers of Teflon felt strips were used to reconstruct the distal stump. We used to infuse GRF glue into the false lumen, but because of the risk of dislodgement of the infused GRF glue and distal embolism, we now only apply it to the outside of the anastomosis. In 13 cases, a 7- to 10-cm-long graft was inserted into the true lumen by the elephant trunk technique as a substitute for placement of the inner Teflon felt strip. Distal anastomosis was accomplished with 4-0 monofilament continuous sutures. In 59 patients (56%), the systemic circulation was arrested throughout the distal repair, but in the 47 patients (44%), retrograde low flow perfusion (10 to 20 mL · kg^-1 · min^-1) through the external iliac artery or femoral artery with or without the use of an occluding balloon positioned in the descending aorta was performed to protect against visceral ischemia. After completion of the distal repair, cardiopulmonary bypass was resumed by using a prefabricated side-arm, and rewarming was started. Arch vessels were reconstructed by the separated graft technique during rewarming when the arch replacement was performed.

The median cross-clamp time was 138 minutes (range, 69 to 437); the median selective cerebral perfusion time was 49 minutes (range, 13 to 231); and the median cardiopulmonary bypass time was 221 minutes (range, 133 to 746). Systemic circulatory arrest was used in 59 patients (56%), and the median arrest time was 55 minutes (range, 21 to 153).

Statistical Analysis
A software package (StatView 5.0 for Macintosh; SAS, Cary, North Carolina.) was used to perform the statistical analyses. The continuous data were reported as means ± standard deviation or as medians and range. Categorical data were expressed as percentages and compared by means of the ² test or a Fisher exact test. Univariate analysis of potential risk factors was performed to identify risk factors for hospital death. All risk factors for hospital death listed in the Appendix were estimated by a ² test or a Fisher exact test, with continuous variables grouped as appropriate. The univariate analysis was followed by a multivariate analysis with a stepwise logistic regression model to identify independent risk factors. A p value of less than 0.05 was considered evidence of statistical significance.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Sixteen patients died postoperatively, and the overall hospital mortality rate was 15.1%. The causes of the hospital deaths were severe brain damage (n = 2), low cardiac output syndrome (n = 3), hemorrhage (n = 4), myonephropathic metabolic syndrome (n = 1), visceral ischemia (n = 1), fatal rupture of a residual descending thoracic aortic dissection (n = 3), graft-versus-host disease (n = 1), and graft infection (n = 1; Table 4).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Recent advances in diagnostic modalities, operative strategies, and postoperative management have resulted in remarkable improvement in the operative mortality of patients with acute type A dissection. Our results showing an overall hospital mortality rate of 15.1% are comparable with the results in other recent reports [4, 9, 10].

Two variables—visceral ischemia and absence of axillary artery perfusion—were identified as significant risk factors of hospital mortality. Visceral ischemia is a catastrophic dissection-related complication and accounted for 15% of the dissection-related deaths; and it has also been determined to be a significant risk factor for hospital death in several other reports [11–13]. The basic mechanism of visceral branch compromise arising from the dissection process has been well described by Crawford and Crawford [14]. The dissection process can lead to expansion of the false lumen and compression of the true lumen, and it can cause obstruction of the aorta and the origins of aortic branches. Moreover, the dissection process may extend into the aortic branch vessels, and occasionally thrombus formation may occur in the dissected branch vessels. This process also can lead to occlusion of branch vessels. Another unusual mechanism of obstruction caused by dissection is intussusception of detached intima. Rational treatment of visceral malperfusion should be considered based on an understanding of the mechanism described above. Proximal aortic repair will redirect blood flow into the true lumen and may suffice to restore distal circulation. Actually, Fann and colleagues [13] have reported that proximal aortic replacement restored distal perfusion in as many as 92% of patients with peripheral vascular compromise secondary to acute dissection. Spontaneous reentry also decompresses the expanded false lumen and relieves obstruction of the true lumen, which explains why surgical or percutaneous balloon fenestration has received much attention. Slonim and colleagues [15] have reported achieving a mortality rate of only 4.5% when they used aortic balloon fenestration and stenting in the treatment of patients with visceral ischemia, but that the mortality rate of all types of surgical aortic fenestration remained high [16–18]. Their results showed the advantages of endovascular fenestration with stenting for rapid relief of malperfusion. In view of the natural history of acute type A dissection, central aortic repair should take precedence over aortic fenestration. However, since the preceding central aortic repair can prolong visceral ischemia and lead to irreversible organ failure [17], measures to prevent visceral malperfusion during central aortic repair are required.

Antegrade perfusion through a cannulated subclavian (or axillary) artery has recently come to be preferred over retrograde perfusion through a cannulated femoral artery as a means of cardiopulmonary bypass in operations for type A aortic dissection [19, 20]. The advantages of providing antegrade arterial flow are based on the avoidance of disadvantages arising from retrograde perfusion such as organ malperfusion caused by elevation of a dissected intima flap or expanding false channel, and the risk of retrograde embolization by thrombus or atherosclerotic debris [21, 22]. Another advantage of antegrade arterial flow is that it redirects flow into the true lumen, decompresses the expanded false lumen, and restores distal perfusion immediately after the cardiopulmonary bypass is established, especially when the intimal tear is located in the ascending aorta; and as a result, irreversible organ damage caused by prolonged visceral ischemia during central aortic repair may be prevented.

Actually, our results demonstrated that hospital mortality decreased after adopting axillary artery perfusion as part of our regular strategy. A review of the exact causes of death revealed that low cardiac output syndrome and bleeding were the main causes of hospital death and contributed to poor outcome in the nonaxillary cannulation group. Elevation of a dissected intimal flap or expandsion of the false lumen produces a fatal damage to the aortic root, coronary artery compromise, and myocardial damage; and that is why coronary artery bypass graft surgery was a more common concomitant procedure and low cardiac output syndrome was the main cause of hospital death in the nonaxillary cannulation group. Van Arsdell and coworkers [23] reviewed 55 autopsy cases of acute type A dissection and found that 24 % of the cases of retrograde perfusion had a secondary intimal injury site. Their results suggested that retrograde perfusion might lead to persistence of the risk of false lumen perfusion and increase the risk of bleeding at the distal anastomosis. Moreover, the distorted aortic root increases the risk of bleeding at the proximal anastomosis. Axillary artery perfusion has prevented fetal low cardiac output syndrome and bleeding, and as a result, has led to a remarkable improvement in the hospital mortality of patients with acute type A dissection.

In conclusion, visceral malperfusion and the absence of axillary perfusion were identified as independent predictors for hospital mortality among patients with acute type A dissection. Axillary artery cannulation is an effective method of further improving the results of surgery for acute type A dissection.

	Appendix

 

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Mr Takenobu Tasaki for valuable help with statistical analysis.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoshimasa Moizumi Naotaka Motoyoshi Kei Sakuma Seijiro Yoshida Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moizumi, Y. Articles by Yoshida, S. Search for Related Content PubMed PubMed Citation Articles by Moizumi, Y. Articles by Yoshida, S. Related Collections Great vessels