Arterial Cannulation in Type-A Dissection in the Era of Antegrade Cerebral Perfusion: Should We Avoid the Femoral Access?

Objectives: The definition of the optimal arterial cannulation site in the setting of aortic dissection type A (AAD) is still controversial and well-established consensus is lacking. Current literature on impact of arterial cannulation and outcome in AAD is clearly biased by the variety of cerebral perfusion strategies. Aim of this study was to evaluation impact of arterial cannulation site on functional outcome and survival in patients undergoing surgical repair for AAD under hypothermic circulatory arrest with antegrade cerebral perfusion (ACP).

Methods: Institutional database disclosed 241 patients undergoing surgical repair for AAD in hypothermic circulatory arrest with ACP between 01/2000 and 04/2019. Patients were divided into two groups according to arterial cannulation: antegrade flow (axillary [n = 125], carotid [n = 11], or direct cannulation [n = 15]) versus retrograde flow (femoral cannulation [n = 90]). Postoperative neurologic injury (PNI) was defined as permanent loss of neurologic function at physical examination and/or brain injury detected on CT or MRI scan.

Results: Patient demographics, as well as surgical therapy, between the two groups did not differ except a higher rate of impaired perfusion of the left carotid artery in patients with antegrade flow. Patients with retrograde flow suffered from higher rates of postoperative neurologic injury (22.7 vs. 11.5% in antegrade flow group, p = 0.027). Risk factor analysis for PNI identified presence of preoperative malperfusion (OR = 3.150, 95% CI: 1.436–6.908, p = 0.004) and preoperative cardiopulmonary resuscitation (OR = 7.019, 95% CI: 1.978–24.909, p = 0.003) as independent risk factors. Application of antegrade flow emerged as preventive factor for PNI (OR = 0.428, 95% CI: 0.205–0.983, p = 0.024). Long-term survival did not differ between the two groups (log rank, p = 0.882).

Conclusion: Antegrade flow in combination with ACP reduces the risk of postoperative neurologic injury in AAD. Surgeons should be encouraged to avoid femoral artery cannulation in type-A aortic dissection. In case of hostile anatomy or hemodynamic compromise carotid cannulation should be considered as quick access for arterial cannulation.