Optimal and Safe Cannulation for Repairing Acute Ascending Aortic Dissection

In operations requiring a cardiopulmonary bypass (CPB), surgery for acute ascending aortic dissection still has high morbidity and mortality. Known major complications are impairment of consciousness and neurologic disability. To improve outcomes, many methods have recently been introduced: varying degrees of systemic hypothermia to increase the hypoxemic tolerance of the brain, and different arterial cannulated sites for brain perfusion. Previously, the CPB was set up using femoral artery cannulation with deep hypothermic circulatory arrest (DHCA) (16-18 °C). Because more neurologic complications were found, other extra-perfusion methods with retrograde cerebral perfusion from the superior vena cava have been used for years. Recently, peripheral right subclavian and axillary artery cannulation have been used, and reported outcomes seem better. Selective cerebral perfusion is another choice for peripheral cannulation. Innominate artery cannulation has also recently become popular. Some surgeons prefer central arterial cannulation, in which the approach is directly from the dissected ascending aorta, to peripheral cannulation, in which the approach is through the cardiac apex. Transapical cannulation consists of inserting the arterial cannula through the apex and the aortic valve so that it lies in the sinus of Valsalva. In summary, cannulation sites for CPB can be peripheral arteries or central arteries. Although we recommend using axillary arterial cannulation, we discuss and summarize the advantages and disadvantages of multiple methods of CPB, and compare clinical outcomes between the two cannulated sites.

Keywords: Antegrade cerebral perfusion, Ascending aortic cannulation, Ascending aortic dissection, Axillary artery cannulation, Brain protection, Cardiopulmonary bypass, Central cannulation, Hypothermia, Hypothermic circulatory arrest, Hypothermic circulatory arrest, Innominate artery cannulation, moderate hypothermia, Perfusion flow, Peripheral cannulation, Retrograde cerebral perfusion, Selective cerebral perfusion, Selective cerebral perfusion, Subclavian artery cannulation, Superior vena cava, Transapical cannulation.