True Lumen Cannulation for the Tool Kit in Type A Aortic Dissection

Dear Sir,

Various cannulation sites and perfusion techniques ranging from antegrade to retrograde perfusion with or without circulatory arrest have been advocated for patients with acute type A aortic dissection. This very interesting article by Urbanski and colleagues describes the cannulation of a common carotid artery to avoid circulatory arrest during reconstruction of the aortic arch in type A aortic dissection [1]. Especially in emergency situations, however, time is required both to expose the carotid artery and to suture a Dacron graft to the carotid artery. The recently rediscovered technique of a direct true cannulation of the transected ascending aorta with subsequent tight circular snare fixation of the cannula allows rapid institution of antegrade flow [2], [3]. Reconstruction of the proximal aortic root can be easily achieved, followed by a period of circulatory arrest where the cannula is temporarily removed and the cannulated segment of the dissected aorta resected, allowing for open inspection of the arch followed by appropriate distal aortic reconstruction. Subsequently, the aortic graft is directly cannulated to resume cardiopulmonary bypass with antegrade arterial perfusion. Recent reports have demonstrated that this technique can be applied easily and safely [3], [4].

The optimal cannulation site for patients with type A dissection is a matter of eternal debate. And probably, as with most eternal issues, a true answer will never be found. True lumen cannulation of the dissected ascending aorta, which was not discussed by Urbanski and colleagues, offers the option of a rapid arterial access with immediate antegrade perfusion and should be considered as an option in surgery for acute type A aortic dissection.

References

• 1 Urbanski P P, Lenos A, Lindemann Y, Zacher M, Frank S, Diegeler A. Use of a carotid artery for arterial cannulation: side-related differences.  Thorac Cardiovasc Surg. 2010;  58 276-279
• 2 Borst H G, Laas J, Heinemann M K. Type A aortic dissection: diagnosis and management of malperfusion phenomena.  Semin Thorac Cardiovasc Surg. 1991;  3 238-241
• 3 Jakob H, Tsagakis K, Szabo A, Wiese I, Thielmann M, Herold U. Rapid and safe direct cannulation of the true lumen of the ascending aorta in acute type A aortic dissection.  J Thorac Cardiovasc Surg. 2007;  134 244-245
• 4 Conzelmann L O, Kayhan N, Mehlhorn U, Weigang E, Dahm M, Vahl C F. Reevaluation of direct true lumen cannulation in surgery for acute type A aortic dissection.  Ann Thorac Surg. 2009;  87 1182-1186