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Eur J Cardiothorac Surg 2008;34:792-796. doi:10.1016/j.ejcts.2008.05.014
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Ascending aortic cannulation in acute aortic dissection type A: the Hannover experience

Nawid Khaladj*, Malakh Shrestha, Sven Peterss, Martin Strueber, Matthias Karck, Maximilian Pichlmaier, Axel Haverich, Christian Hagl

Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany

Received 18 November 2007; received in revised form 24 April 2008; accepted 9 May 2008.

* Corresponding author. Tel.: +49 511 532 6581; fax: +49 511 532 5404. (Email: Khaladj.Nawid{at}mh-hannover.de).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Objective: The incidence of embolic events and of cerebral malperfusion in aortic dissection type A (AADA) must be viewed in the context of the existence of a number of possible cannulation techniques. Since femoral cannulation is thought to be associated with a higher risk of perfusion of the false lumen and retrograde embolization, techniques establishing antegrade flow may provide a better option. We describe herein our experience with ascending aortic cannulation in this special patient population. Methods: Between November 1999 and February 2006, 122 patients underwent operation for AADA with arterial access via the dissected ascending aorta. The aorta was cannulated at the site of the minimal distances of the dissected layers. Double purse-string sutures were used to support the cannula. Pressure monitoring in both radial arteries as well as bilateral cerebral oxygen saturation measurement helped to identify malperfusion after establishment of cardiopulmonary bypass. Aortic arch as well as aortic root surgery was performed, as dictated by the pathology. Selective antegrade cerebral perfusion and moderate hypothermia were used for brain and body protection. Results: Malperfusion occurred in three patients (2.5%). Hospital mortality was 15% for the entire cohort (18 patients). Permanent neurological dysfunction was detected in 15 patients (12%), whereas temporary neurological dysfunction occurred in 21 (17%). Total arch replacement was performed in 31 patients (25%). Conclusion: Direct cannulation of the ascending aorta is an easy and safe method in patients with AADA. This technique, which also avoids retrograde flow in the downstream aorta, is an alternative to time-consuming axillary artery access.

Key Words: Acute aortic dissection • Arterial cannulation side • Aortic surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Arterial access for establishing cardiopulmonary bypass (CPB), especially in patients requiring repair of acute aortic dissection type A (AADA), is currently a controversial subject [1]. In addition to the conventional option of femoral cannulation, different methods of achieving antegrade access for elective and emergent procedures have been introduced during the last few years [2–9]. A simple and easy technique of direct cannulation of the dissected aorta was published by our group in 2003 [10], followed by various modifications by others [11,12]. We describe our experience during the last several years with this technique in a series of patients with AADA that were all operated on at our institution under moderate hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SACP), using a standardized protocol for cardiopulmonary bypass and cerebral protection [13].


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
This retrospective study was approved by the institutional review board; no individual patient consent was required.

From November 1999 to February 122 patients with AADA underwent emergent ascending aortic replacement under HCA and SACP at our institution. Median age was 63 years (range 20–88 years); 79 were male. Further preoperative data are shown in Table 1 .


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  		Table 1 Demographic and preoperative data
 
All patients were transferred to the operating theatre as soon as the diagnosis of AADA was confirmed, in the majority of cases by computed tomography scanning (CT). No patient was refused surgery as a consequence of his preoperative status (advanced age, hemodynamic instability, or unknown neurological status). Surgery was performed through a median sternotomy. Central cannulation was attempted in all patients. After systemic heparinization, the ascending aorta was cannulated at a less dissected or non-dissected area, as determined by means of preoperative CT-scans and intraoperative transesophageal echocardiography (TEE), if available. Double purse-string sutures were used to support the cannula (Prolene 4-0 RB1 Ethicon GmbH, Norderstedt, Germany) (Fig. 1 and Video 1). The position of the cannula was immediately verified by TEE (Fig. 2 ). Venous return was established with a two-stage cannula introduced via the right atrium. With pressure monitoring in both radial arteries and one femoral artery, as well as bilateral cerebral oxygen saturation monitoring (INVOS®, Somanetics, Troy, MI, USA), cardiopulmonary bypass (CPB) was initiated and the patient cooled to the target temperature. During this period, cold blood cardioplegia was administered into the coronary ostia, and after careful inspection of the valve, a decision was made about the subsequent root procedure.


Figure 1
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  		Fig. 1. Arterial cannula in position in a patient with AADA.

 

Figure 2
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  		Fig. 2. Intraoperative transesophageal echocardiography showing the cannula correctly positioned in the true lumen of the ascending aorta.

 
After reaching the anticipated HCA temperature, CPB was stopped, the aorta was opened, and the arterial cannula removed. Following exploration of the aortic arch, two 15 F retrograde cardioplegia catheters (RCSP MR 20, Medtronic, Minneapolis, MN, USA) were introduced under direct vision into the innominate and left carotid arteries. After meticulous de-airing, SACP (regulated to maintain a pressure of 50 mmHg) was initiated with cold blood at 14 °C as described previously [13]. The arch and the aortic root were repaired as dictated by the pathology and the surgeon's preference. Supracommissural aortic replacement was performed whenever the root was not involved in the dissection and no aortic insufficiency was present. Otherwise, the aortic root was preserved whenever possible using the techniques described by David or Yacoub, or a stabilization procedure introduced by our group was utilized [14]. In cases where a root replacement was necessary, a button Bentall procedure with a commercially available mechanical or homemade biological conduit was performed. Major intra-operative data are summarized in Table 2 .


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  		Table 2 Intraoperative data and surgical procedures
 
Postoperative neurological evaluation was focused on discriminating between permanent neurological dysfunction (PND) (frank stroke) and temporary neurological deficits (TND), according to the definition of Ergin and co-workers [15]. Patients with PND were excluded for analysis of TND. PND and TND were included in the results even when the patient died subsequently.

2.1 Statistical analysis
Results were expressed as mean ± standard deviation, median plus range or percentage, respectively. Statistical analysis was performed using SPSS 14.0 software (SPSS Inc., Chicago, IL, USA).


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusion
 Appendix A
 References
 
The intent of this study was not to compare different cannulation sides, but to take a closer look in a large series of patients at the pitfalls that can occur. Over the seven-year experience, six staff surgeons performed this type of procedure. Twenty-eight patients were cannulated via the femoral artery according to the surgeon's preference.

In three cases (2.5%), malperfusion occurred after ascending aortic cannulation. Malperfusion was anticipated if a cerebral saturation difference of 10% occurred or a drop towards lower values was detected and/or a pressure difference between left and right radial artery of greater than 20 mmHg occurred.

In one of the patients, the catheter was misplaced during cannulation under continuous cardiac massage. Immediately after detection of pressure differences between the radial arteries, the aorta was opened during a brief period of circulatory arrest: an incision was made in the membrane between the true and false lumens; the cannula was repositioned, and CPB re-established. In the second patient, near infrared spectroscopy revealed a decrease in saturation in the left hemisphere of the brain. Transapical cannulation was performed to re-establish CPB, but additional femoral artery cannulation was also necessary to achieve adequate perfusion pressures. Aortic rupture occurred in the third patient after establishing CPB. From the intraoperative course it seemed that rupture occurred spontaneously after establishing CPB. In this patient, circulatory arrest was induced immediately; cold SACP was administered after opening the aortic arch, and isolated crystalloid cardioplegia was given directly into the coronary ostia.

The majority of patients underwent open distal anastomosis for arch replacement (75%). Further intraoperative data are shown in Table 2. Concomitant coronary artery surgery was performed if the coronary ostia were involved in the dissection or significant coronary artery disease was present.

The aortic root was treated with the methods mentioned above, according to the pathology and the surgeon's preference. An attempt was made also to consider significant individual patient characteristics (e.g., age, hemodynamic and neurological status, need for further anticoagulation, expected duration of HCA) that might impact upon this decision.

3.1 Outcome
Thirty-day mortality was 15% (18 patients) for the entire cohort. PND occurred in 15 (12%); TND was detected in 21 patients (17%). Two patients in each group (with TND and PND) died during their hospital stay.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusion
 Appendix A
 References
 
Acute aortic dissection type A presents an emergency situation that requires immediate surgical intervention. Recent advances in preoperative recognition and anesthesiological management as well as operative techniques have significantly improved early outcome, but morbidity and mortality remain a matter of concern among most cardiothoracic surgeons [16]. In the clinical situation, most of the patients with AADA present with an incomplete medical history, a more-or-less unclear neurological situation and an unknown burden of comorbidity. Therefore, an individual patient's risk can be only roughly estimated in the emergency situation [17].

The problem of neurological injury due to embolic events and cerebral malperfusion due to aortic dissections has to be discussed with the knowledge that there are a number of possible cannulation techniques. Femoral cannulation is associated with a higher risk of retrograde embolization and potential perfusion of the false lumen via the distal re-entry point. Techniques providing antegrade flow may provide a better option, especially in patients with AADA [18].

In our institution, cannulation of the ascending aorta/aortic arch is the standard approach for arterial access in elective as well as emergency cases [10,13]. This straight forward technique is fast, which can be an important issue, especially in hemodynamically unstable patients. It avoids additional time-consuming incisions causing a reduction of the already existing substantial surgical trauma. In combination with cold SACP and moderate hypothermic circulatory arrest, this technique provides adequate protection for the body and is not associated with an increased risk of potential cerebral micro-emboli [19,20]. The effectiveness of SACP as an adjunctive to moderate hypothermia has been proven by numerous investigations [21,22]. As with other surgical approaches, there are drawbacks, which have to be kept in mind. This includes cannulation of the false lumen with potential malperfusion or even complete rupture of the cannulated aorta. In those cases, back door strategies have to be available. In this situation there are basically three major goals which have to be achieved: First, the protection of the brain, second the protection of the heart and finally the perfusion of the lower body.

All three goals can be achieved by a stepwise approach. As in a recipe, SACP has to be established right after circulatory arrest, followed by administration of cardioplegia, and finally cooling of the lower body by insertion of a cannula or bladder catheter via the opened aortic arch in the descending aorta. This stepwise approach has to be kept in mind by the anesthesiologist, the perfusionist and the surgeon performing the procedure. A malposition rate of 2.5% in this series is in our opinion acceptable when compared to the results published by others.

The procedure described by Reece and co-workers used the Seldinger technique for introduction of the cannula in 24 cases, resulting in no misplacement [12]. However, the study is not random, and various aortic pathologies were excluded, creating a potential selection bias. Furthermore, the cannula has to be held in position manually during cooling, since the authors are not convinced that sutures in the dissected aorta will hold. Inoue and co-workers present their experience in 32 cases, also using the Seldinger technique, guided by epiaortic ultrasound. Prior to ascending aortic cannulation, these authors use femoral cannulation to start CPB [11]. Although no malperfusion occurred in their series, this technique is questionable in the context of avoiding time-consuming preparations and potential retrograde embolism [1].

Transapical cannulation may be another elegant option for achieving easy and rapid antegrade access, as described by Wada and colleagues [8]. In a large series of 138 patients (129 with AADA), the cannula was safely introduced through a 1 cm hole in the left apex directly into the true lumen of the dissected aorta under TEE guidance. The impact of increasing or provoking new aortic insufficiency in this context is not discussed in detail. This technique as well the technique from University of Virginia have the disadvantages of producing prolonged cardiopulmonary bypass times, since no additional procedures can be performed during cooling, such as inspection and preparation of the aortic root.

Axillary cannulation is an elegant method for arterial access during aortic arch surgery [7]. However, it is presumably more time consuming, and carries the disadvantages of failure rates as high as 4.2%. Nevertheless, it has the advantage of providing continuous unilateral blood flow without interruption [6]. Without modifications, however, only one hemisphere is continuously perfused, which can lead to inadequate perfusion of the left hemisphere, as Merkkola and co-workers have shown that in up to 17% of the patients an incomplete circle of Willis is present [23]. Moizimi and co-workers could not use axillary artery access in 5.5% of their AADA cohort, as the dissection extended into the axillary artery (4/73 patients) [4]. Carotid artery cannulation, performed by Urbanski and co-workers in 100 patients so far, including 27 with AADA, seems to be another elegant method, but also carries the risk of brain malperfusion as described above [9]. The experience with innominate artery cannulation by Di Eusanio and co-workers includes 55 patients with only two in AADA [24].

Fusco and co-workers presented their results in femoral artery cannulation in patients with AADA in 2004 [3]. With a conversion rate of 2.5% to ascending aortic cannulation (2/79 patients), they conclude that femoral cannulation is appropriate and yields excellent clinical results. They are not aware of having encountered retrograde embolism from the downstream aorta, probably since arteriosclerosis is less common in dissection patients in their experience and that of others.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
Appendix A
 References
 
Direct aortic cannulation is an easy, fast and straight forward technique in patients with AADA. From our experience it is safe and allows a prompt induction of CPB. The technique avoids retrograde flow in the aorta, and is an alternative to the more time-consuming axillary artery access.

The authors are convinced that there is currently no optimal cannulation technique available thus far in the subset of patients requiring surgery for AADA. The most important consideration is that the technique used in this emergency setting is one with which the team has experience under elective conditions, no matter whether or not it provides antegrade flow via the ascending aorta, the axillary or even the carotid artery, or whether retrograde, via the conventional femoral approach. We have come to the same conclusion as the Ennker group in their recent review: it is too early for a general recommendation concerning the best cannulation site [25].


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
References
 
Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ejcts.2008.05.014.


   Footnotes
 
{star} Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.

{star}{star} This work was supported by the German Research Foundation (HA 2971/2-2).


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 

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