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Ann Thorac Surg 2009;87:1182-1186. doi:10.1016/j.athoracsur.2009.01.027
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Reevaluation of Direct True Lumen Cannulation in Surgery for Acute Type A Aortic Dissection

Lars O. Conzelmann, MD*,*, Nalan Kayhan, MD*, Uwe Mehlhorn, MD, Ernst Weigang, MD, Manfred Dahm, MD, Christian F. Vahl, MD

Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg-University Mainz, Germany

Accepted for publication January 13, 2009.

* Address correspondence to Dr Conzelmann, Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg-University, Langenbeckstr. 1, Mainz, 55131, Germany (Email: lars.conzelmann{at}gmx.de).

Presented at the Fifth Joint Meeting of the German, Austrian and Swiss Societies for Thoracic and Cardiovascular Surgery in Innsbruck, Austria, Feb 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Footnotes
 Acknowledgments
 References
 
Background: The optimal mode of arterial cannulation in acute type A aortic dissection is controversial. We retrospectively investigated our experience with direct true lumen cannulation as an alternative to standard cannulation procedures.

Methods: From April 2004 to August 2007, 29 patients (20 men, 9 women; mean age of 63.2 ± 12.6 years) underwent emergency operation for acute type A aortic dissection with direct true lumen cannulation. After venous drainage into the venous reservoir, the ascending aorta was completely transected in the region between the sinotubular junction and innominate artery. After visual and digital identification of the true lumen, the arterial cannula was directly inserted into the true lumen and secured with a ligature.

Results: Mean aortic cross-clamp time was 77.4 ± 28.3 minutes, and hypothermic circulatory arrest for the distal anastomosis was 10.4 ± 11.0 minutes. All patients survived the surgical procedure. No surgical problems were observed by applying this strategy. Mean intensive care unit stay was 4.0 ± 3.5 days. Postoperative mean ventilation time was 43.3 ± 41.3 hours. One patient had a prolonged postoperative course and required permanent ventilation. Two patients required temporary hemofiltration. Neurologic disorders occurred in 6 patients: 2 had severe cerebral hypoxia, and 4 had temporary hemiplegia under good regression. All patients were alive at discharge.

Conclusions: Direct true lumen cannulation is a promising surgical strategy for emergency operations in type A aortic dissection. It is a simple, quick, and safe method to provide antegrade flow through the true aortic lumen.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Footnotes
 Acknowledgments
 References
 
Current concepts of arterial cannulation in type A dissection include femoral, subclavian, axillary, or carotid artery, transapical or aortic cannulation [1–8]. All of these procedures are associated with advantages and disadvantages. The presence of aortoiliac aneurysms, severe peripheral occlusive disease, atherosclerosis of the femoral vessels, and distal extension of the aortic dissection may reduce the use of the common left femoral approach. Thus for some patients, axillary artery cannulation has been suggested as a safer and more effective means of providing arterial inflow during cardiopulmonary bypass (CPB) [9, 10]. Similarly, carotid artery cannulation has been described as a fast and efficient method [8]. With these cannulations, a unilateral cerebral perfusion during systemic circulatory arrest is also possible [11].

All of these cannulation sites have their disadvantages, however. First, these techniques are an additional surgical procedure requiring valuable time. Second, as with any cannulation method, inappropriate perfusion of the false lumen may result. Therefore, the optimal arterial cannulation site in acute type A aortic dissection is still controversial. More than a decade earlier, Borst and colleagues [12, 13] performed technique of direct true lumen cannulation of the ascending aorta when obstruction of the true lumen occurred at the commencement of retrograde perfusion. Recently, Jakob and colleagues [14] reported their good experience in 8 patients with this direct cannulation of the true lumen in acute type A aortic dissection.

Direct cannulation of the true aortic lumen after transection of the ascending aorta was used in our institution in surgical treatment of type A dissection. The present retrospective study was designed to provide perioperative data of this high-risk population and to prove the applicability of this technique.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Footnotes
 Acknowledgments
 References
 
Patients
Between April 2004 and August 2007, 29 consecutive patients, 20 men (69%) and 9 women (31%), underwent emergency operation for acute type A aortic dissection with direct true lumen cannulation at our institution. No other cannulation sites were used during this time period. Patients were a mean age of 63.2 ± 12.6 years. All data were gathered by retrospective review of patient medical records. The ethics committees approved the study and waived the need for patient consent. The patient's characteristics are summarized in Table 1. All values are given as mean ± standard deviation.


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  		Table 1 Patient Demographics and Preoperative Data
 
Preoperative Technique
Patients were placed in the standard supine position. Arterial pressure was monitored with 2 arterial lines, 1 in the right radial artery, and 1 in the left femoral artery. Body temperature was controlled by a rectal or intravesical and an esophageal probe. Neurologic monitoring was performed routinely with a cerebral oximeter (INVOS Somanetics, Troy, MI) to control cerebral perfusion. The head was additionally cooled with local ice packs during circulatory arrest. To visualize the extent of aortic dissection during the procedure, transesophageal echocardiography was routinely performed. No pharmacologic neuroprotective drugs were administered.

Operative Procedure
After median sternotomy, the pericardium was opened. A Mersilene ligature tape (Johnson & Johnson Medical GmbH, Norderstedt, Germany) was placed around the ascending aorta for later snaring. The patient was ventilated using pure oxygen. The venous blood was drained rapidly through the right auricle by using a standard 50/36F two-stage cannula (Type V112, Sorin Group, München, Germany) into the venous reservoir until systolic pressure was lower than 30 mm Hg.

The patient was then put in Trendelenburg position, and the ascending aorta was transected in the region between the sinotubular junction and the innominate artery. Thus, the ascending aorta full of blood still could be inspected and the true lumen identified. A standard 2-hole 24F arterial cannula with a straight tip (HK46SM91V, Maquet, Hechingen, Germany) was directly inserted into the true lumen and secured with the Mersilene ligature tape (Fig 1). By using this technique, the jet of the blood stream is not directed against the aortic wall, thus probably preventing further damage to the aortic wall from the "fire hose" effect. This delicate procedure happened under normothermia and took less than 2 minutes, similar to Jakob and colleagues [14].


Figure 1
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  		Fig 1. Direct true lumen cannulation: After venous drainage (V), the ascending aorta (A) was transected and the true lumen identified. The arterial cannula (C) was inserted into the true lumen and secured with a Mersilene ligature tape (L). Selective cardioplegia was applied into both coronary ostia (S).

 
CPB was then instituted, and the patient was cooled to a designated temperature. Routinely, blood flow through the cannula did not exceed 4 L/min to avoid damage to the wall. The acid-base balance was adjusted using the {alpha}-stat method. Antegrade perfusion of the brain, the abdominal organs, and the lower extremities through the true lumen was guaranteed. The diseased tissue of the ascending aorta—usually up to the origin of the innominate artery—was resected, and cardioplegic solution was given directly into both coronary ostia. The aortic root was reconstructed by reinforcement with a 3- to 5-mm-wide Teflon felt strip (PTFE felt, Impra, Tempe, AZ), and if necessary, the aortic valve was reconstructed using commissural resuspension. The proximal anastomosis of the supracoronary graft replacement (tubular Dacron graft, Braun Aesculap, Tuttlingen, Germany) was done during the cooling phase. The felt strip was included into the anastomosis and the graft intussuscepted into the aortic stump.

At the desired temperature, circulatory arrest was initiated, the arterial cannula was removed together with the dissected ascending aorta, and the aortic arch was inspected. If necessary, intimal tears were oversewn. The dissected distal downstream aorta was reconstructed by felt reinforcement similar to the root. The distal anastomosis was performed in the same intussuscepting fashion as the proximal anastomosis. Thereafter, the aortic cannula was placed directly into the tube graft, and antegrade perfusion was restored after appropriate air removal. After rewarming to normothermia, the patient was weaned from CPB.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Footnotes
 Acknowledgments
 References
 
Preoperative Data
Upon admission to the hospital, 2 patients (7%) went to the operating room under resuscitation, and 16 (55%) presented with a pericardial tamponade. Arch vessel dissection was present in 14 patients (48%). An aortic incompetence greater than grade III was seen in 14 patients (48%), and 8 (28%) had a significantly reduced ejection fraction. Five patients (17%) had neurologic disorders, including 3 (10%) with hemiplegia, 1 (3%) had a numbness of the right leg, and 1 (3%) had an epileptic seizure. The neurologic status in 3 patients (10%) was unknown when they were transferred to the operating room (Table 1).

Intraoperative Data
There were no technical problems with this method. Cannulation of the ascending aorta was safely performed in all cases, and no conversion of the cannulation site was required. No malperfusion by the technique of cannulation and perfusion became evident during CPB. Mean operative time was 269 ± 143 minutes. Mean time from skin incision to initiation of CPB was 22.2 ± 12.5 minutes, and CPB time was 139 ± 88 minutes. Mean aortic cross-clamp time was 77 ± 28 minutes. For distal anastomosis, circulatory arrest was 10.4 ± 11.0 minutes. Organ protection was performed under hypothermia of 27.4° ± 5.7°C. Detailed operative procedures are summarized in Table 2. No additional intraoperative progression of type A dissection was observed by transesophageal echocardiography. All patients survived the surgical procedure and were transferred to the intensive care unit for further observation (Table 2).


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  		Table 2 Perioperative Data
 
Postoperative Data
The mean hospital stay was 12.5 ± 6.7 days and no patients died before discharge from the hospital. Mean intensive care unit stay was 4.0 ± 3.5 days. Mean ventilation time was 43.3 ± 41.3 hours, excluding 1 patient (3%) who had a prolonged postoperative course and required permanent ventilation. This patient already was somnolent and hemiplegic preoperatively. Severe cerebral hypoxia occurred in 2 patients (7%). Temporary hemiplegia, under good regression, occurred in 4 patients (14%). One of these patients (3%) was already hemiplegic preoperatively. No gastrointestinal problems occurred. Two patients (7%) needed temporary hemofiltration; 1 additional patient (3%) was already in a dialysis program (Table 3).


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  		Table 3 Postoperative Data
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Footnotes
 Acknowledgments
 References
 
One of the major problems associated with type A dissection is inadequate organ perfusion. For all patients showing no direct organ dysfunction as long as antegrade flow is preserved, the true lumen cannulation is a concept that avoids the interruption of antegrade flow. This technique should not be expected to create additional new perfusion problems. In those patients with transient neurologic signs, such as weakness of the arm or intermittent or complete hemiplegia, direct true lumen cannulation can be performed under visual control in a way that ensures correct perfusion of the vessels originating from the aortic arch. Antegrade perfusion of the true aortic lumen can be considered a substantial advantage compared with other methods.

The data presented here support the concept that direct true lumen cannulation may be used as a standard strategy for an emergency operation in type A aortic dissection. Because type A dissection is a dynamic disease, the preoperative diagnostic data may not reflect the problems of the patient at the time of operation. Hypothesizing that antegrade true lumen perfusion is beneficial, the surgeon has the option to control the pathoanatomic situation by placement of the arterial cannula into the true proximal aortic lumen.

Cannulation of the ascending aorta in acute type A aortic dissection has been avoided due to its poor results [2]. One study [6] used a Seldinger technique to cannulate the ascending aorta in addition to the femoral artery with satisfactory results. Just recently, direct true lumen cannulation was reported as a simple, safe, and quick alternative arterial cannulation site for the treatment of type A dissection [14]. A minor technical difference between this and our method is the way of securing the arterial cannula: Jakob and colleagues use a clamp; however, we snare the ascending aorta with a Mersilene tape. Both methods are similar to a former cannulation technique already described in the 1990s by Borst and colleagues, where a Y-piece with a second arterial line was used to be inserted into the true lumen of the proximal aorta [12, 13]. This approach was only used when obstruction of the true lumen occured at the commencement of retrograde perfusion.

In the present study, direct true lumen cannulation was technically feasible in all patients. There were no limitations, even in obese or atherosclerotic patients. No conversion to another cannulation site was necessary. Technical simplicity and speed by saving time to gain an additional arterial access are major advantages of this method. The mean time from skin incision to the beginning of extracorporeal circulation was 22 minutes. This led to prompt establishment of antegrade systemic perfusion, which has been described as being beneficial [3, 6]. The major advantage of direct true lumen cannulation is the remaining antegrade blood flow through the true lumen, which may avoid further dissection, cerebral embolization through mobilized calcified debris, and organ malperfusion. In peripheral cannulation sites, such as axillary, subclavian, or femoral arteries, the risk of false lumen cannulation still remains when the peripheral artery is involved in the dissection [10, 15]. This is relatively uncommon for the right subclavian/axillary artery [13]. Another disadvantage of peripheral approaches is the reported limited success rate of cannulation, about 95% for the axillary artery [16]. Furthermore, the pump flow may be affected in peripheral cannulation sites by potentially diminutive arteries in small patients [17].

Especially in patients with hemodynamic instability, peripheral arterial inflow may not be suitable for rapid establishment of CPB. Peripheral vascular disease and severe atherosclerosis are most widely considered as contraindications for peripheral cannulation techniques. In those patients, the true lumen approach can provide an excellent alternative.

Because this technique does not require an additional incision for peripheral cannulation, there were no additional site-specific intraoperative complications, such as blood loss or kinking of the cannula, or postoperative complications, such as wound healing disturbances, infections, brachial plexus injuries, or vascular compromise [17].

The in-hospital mortality rate of 0% after operations for acute type A aortic dissection in the present study is very satisfactory and in concordance with reported results [14]. Published mortality rates vary from 0% to 44% for these patients when different cannulation sites are used (Table 4) [18–26]. Independent from the cannulation technique, the operative mortality is determined by the preoperative hemodynamic instability. Patients in shock have a significantly higher operative mortality rate than cardiocirculatory stable patients [19].


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  		Table 4 Cannulation Sites and Outcome a
 
Deep hypothermic circulatory arrest at 15°C that exceeds 29 minutes has been associated with neurologic dysfunction, stroke, and death [27]. In 3 of our patients (10%), circulatory arrest was prolonged at 31, 38, and 41 minutes. Two of these patients (7%) had temporary hemiplegia, but no persistent neurologic disorders resulted. Renal failure requiring hemofiltration occurred in 2 patients (7%), which is comparable with published data [23]. Mesenteric ischemia is a devastating dissection-related complication and has been determined to be a significant risk for in-hospital death [5, 12, 13]. No mesenteric ischemia was observed in the present study. We assume that this relatively low incidence of organ dysfunction was positively influenced by the rapid establishment of stable antegrade perfusion, which prevented prolonged and potentially deleterious ischemia.

The current study reports a preliminary experience with direct true lumen cannulation in surgical repair of acute type A aortic dissection. The limitations are the relatively small number of patients and the nonrandomized, retrospective design.

In conclusion, direct true lumen cannulation is a promising surgical cannulation technique for emergency surgery in type A aortic dissection with good results. It is a simple, quick, and safe method to provide antegrade flow through the true aortic lumen.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Footnotes
 Acknowledgments
References
 
We thank Beate Tomoschat for valuable help with database research.


   Footnotes
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Footnotes
Acknowledgments
 References
 
* These authors contributed equally to this work. Back


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Footnotes
 Acknowledgments
 References
 

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  10. Pasic M, Schubel J, Bauer M, et al. Cannulation of the right axillary artery for surgery of acute type A aortic dissection Eur J Cardiothorac Surg 2003;24:231-236.[Abstract/Free Full Text]
  11. Kazui T, Inoue N, Yamada O, Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment Ann Thorac Surg 1992;53:109-114.[Abstract/Free Full Text]
  12. Borst HG, Laas J, Heinemann M. Type A aortic dissection: diagnosis and management of malperfusion phenomena Semin Thorac Cardiovasc Surg 1991;3:238-241.[Medline]
  13. Borst HG, Heinemann MK, Stone CD. Surgical treatment of aortic dissectionNew York: Churchill Livingston Inc; 1996.
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  16. Strauch JT, Spielvogel D, Lauten A, et al. Axillary artery cannulation: Routine use in ascending aorta and aortic arch replacement Ann Thorac Surg 2004;78:103-108.[Abstract/Free Full Text]
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  19. Long SM, Tribble CG, Raymond DP, et al. Preoperative shock determines outcome for acute type A aortic dissection Ann Thorac Surg 2003;75:520-524.[Abstract/Free Full Text]
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  21. Nouraei SM, Nouraei SA, Sadashiva AK, Pillay T. Subclavian cannulation improves outcome of surgery for type A aortic dissection Asian Cardiovasc Thorac Ann 2007;15:118-122.[Abstract/Free Full Text]
  22. Reece TB, Tribble CG, Smith RL, et al. Central cannulation is safe in acute aortic dissection repair J Thorac Cardiovasc Surg 2007;133:428-434.[Abstract/Free Full Text]
  23. Reuthebuch O, Schurr U, Hellermann J, et al. Advantages of subclavian artery perfusion for repair of acute type A dissection Eur J Cardiothorac Surg 2004;26:592-598.[Abstract/Free Full Text]
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