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Year : 2023  |  Volume : 11  |  Issue : 1  |  Page : 28-33

Double-arterial cannulation strategy in patients presenting with Type A aortic dissection: An Indian tertiary cardiac center experience

Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Ahmedabad, Gujarat, India

Date of Submission31-Jan-2023
Date of Decision18-Mar-2023
Date of Acceptance20-Mar-2023
Date of Web Publication12-Apr-2023

Correspondence Address:
Praveen Nayak
Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Asarva, Ahmedabad - 380 016, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_9_23

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Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality.
Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality.
Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes.
Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs.
Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.

Keywords: Antegrade cerebral perfusion, ascending aortic dissection, deep hypothermic cardiac arrest, double-arterial cannulation, retrograde cerebral perfusion, single-arterial cannulation

How to cite this article:
Patel A, Nayak P, Singh R, Doshi C. Double-arterial cannulation strategy in patients presenting with Type A aortic dissection: An Indian tertiary cardiac center experience. Heart India 2023;11:28-33

How to cite this URL:
Patel A, Nayak P, Singh R, Doshi C. Double-arterial cannulation strategy in patients presenting with Type A aortic dissection: An Indian tertiary cardiac center experience. Heart India [serial online] 2023 [cited 2023 May 31];11:28-33. Available from: https://www.heartindia.net/text.asp?2023/11/1/28/374107

  Introduction Top

Despite advancements in diagnostic tools, management algorithms, and surgical techniques in the past decades, complex aortic arch surgery and ascending aortic dissection (AAD) remain challenging for cardiothoracic surgeons. This is primarily due to the need for a bloodless operating field along with the intent of providing maximum cerebral protection. The most commonly used strategy for AAD is deep hypothermic circulatory arrest (DHCA) alone or in varying combinations with antegrade cerebral perfusion (ACP)/retrograde cerebral perfusion (RCP).[1] Deep hypothermic cardiac arrest allows the clean bloodless field which is ideal to work. However, it does pose a potential threat of grave neurological damage. It has well been proven that the same time of DHCA in different individuals leads to varied outcomes ranging from being completely asymptomatic to even stroke.

The inhospital mortality rates for acute aortic dissection Type A have been reported between 18% and 25% by the International Registry of Acute Aortic Dissection, and around 17% by the German registry.[2] It is vital to establish early and effective arterial inflow in patients having acute aortic dissection with dissection flap extending into major vessels using cardiopulmonary bypass (CPB) and avoid malperfusion.[3] However, achieving good flow in CPB might be challenging and depends on the extent of dissection, vascular anatomy of individual, and surgical expertise.[4],[5] Single-arterial cannulation (SAC) using femoral artery might not adequately perfuse brain, and single-right axillary cannulation might not perfuse the lower part of the body well. The present study aimed to compare the perioperative and early outcomes of double-arterial cannulation (DAC) with ACP under moderate hypothermia with those of SAC without ACP/RCP under DHCA, based on a retrospective analysis of the experiences of a tertiary-level referral cardiac surgery center.

  Materials and Methods Top

The present study was conducted in the Department of Cardio-Vascular and Thoracic Surgery associated with the UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, one of the tertiary cardiac referral units of Western India. This was a retrospective analysis of surgical outcomes of 64 patients with acute Type A AAD extending into aortic arch and major vessels, who were admitted at our center and operated between July 1, 2015, and July 31, 2020.

Thirty patients operated by SAC technique and 34 patients by DAC technique were included in the study and their operative note and inpatient files were studied and data were collected. As this was a retrospective analysis of the surgical outcomes of the surgical technique, prior ethics committee approval was not taken.

The patients with complex aortic arch disease and associated conditions were evaluated with computerized tomography (CT) aortogram with three-dimensional (3D) reconstruction [Figure 1] and conventional angiography if required along with routine blood investigation and two-dimensional echocardiogram. Those with chronic aortic dissection were excluded from the study. Patients who presented to the emergency room were urgently evaluated and hemodynamically stabilized, their heart rate and blood pressures were optimized and clinical examination was performed to rule out malperfusion in the abdomen and limbs. Patients who presented with shock were resuscitated with fluids, and on-site echocardiography was performed. In those diagnosed with cardiac tamponade, pericardial fluid was drained and the patients were shifted to operating room.
Figure 1: Preoperative computerized tomography scan (volume-rendering technique reconstruction)

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Operative procedure

The right axillary artery was dissected and looped proximally and distally. Systemic heparinization was done and 7 mm Dacron graft was anastomosed end to side and the graft was clamped [Figure 2]. Femoral arterial cannulation was done on the side depending on the extent of dissection flap. Open cannulation with 7 mm Dacron end-to-side anastomosis with femoral artery in 47 patients [Figure 3] and open direct technique in 13 patients. Median sternotomy was done and anatomy was assessed. The right atrium was cannulated with a dual stage cannula in 22 patients. In the remaining 42 patients who were having very large aortic aneurysm and also in those patients who were having aortic dissection almost abutting the right atrium, femoral venous cannulation was done just for convenience to keep minimal cannulas in operating field. A retrograde cardioplegia cannula was placed into the coronary sinus and CPB was initiated and systemic cooling was initiated. Right radial artery pressure was monitored and was kept between 50 and 70 mmHg. We mobilized ascending aorta and dissected innominate artery and looped at its base. Similarly, left common carotid, subclavian, and descending aorta was looped [Figure 4]. Retrograde cardioplegia was started and aortic. Cross clamp was applied just proximal to the base of innominate artery, and the heart was arrested. The type of surgery done is presented in [Table 1].
Figure 2: Cannulation strategy

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Figure 3: Axillary artery cannulation using 7 mm graft

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Figure 4: Femoral cannulation using 7 mm graft

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Table 1: Surgical procedures

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During DAC technique using the femoral and right axillary artery, the patient was cooled to keep temperature in between 24° and 28° and the innominate artery was snugged and the period of circulatory arrest was initiated and the aortic arch was opened and the extent of dissection was assessed and distal anastomosis of the graft was started, and just at the end of anastomosis, rewarming was started and the distal anastomosis was completed and gradual CPB flow was restored. The patient was rewarmed and the axillary arterial graft was occluded and the right radial arterial pressure was monitored, and on achieving adequate pressure, the axillary graft was discontinued and CPB was maintained with the femoral cannula and later discontinued after satisfactory cardiac activity.

During SAC technique using the femoral or right axillary artery, DHCA was done keeping temperature between 18° and 20° and distal anastomosis of the graft was completed and CPB was restored gradually.

Out of all patients who were operated for aortic disease during the study period, 64 patients fulfilled the study criteria and their files were studied and requisite medical history and the demographic details were recorded and tabulated and the outcomes were monitored. Follow-up CT aortogram with 3D reconstruction was checked [Figure 5].
Figure 5: Postoperative computerized tomography scan showing almost normal arch with well-flowing branches

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The results were compared with patients who underwent aortic surgery by SAC technique during the study period, and statistical analyses were performed using the IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). Univariate analyses done by using different statistical tests and differences in clinical demographics, surgical information, and postoperative complications were determined. For all analyses, statistical significance was set at P < 0.05.

  Results Top

The study included 64 patients who fulfilled the inclusion criteria; the patients included in the study were young in age (25–55 years; mean: 37.5 years), majority being males (43/64) [Table 2]. More than 60% of the patients had hypertension as the associated comorbidity. Ten percent of patients had features of Marfan's syndrome.
Table 2: Gender-wise distribution of study participants

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The patients operated by using DAC technique had fewer postoperative complications [Table 3]; in our study, none of the patients had stroke in perioperative period. Malperfusion-related complications were also less in the DAC group, one patient underwent hemodialysis in the SAC group, and none of the patients in DAC had to undergo hemodialysis for acute kidney injury (AKI). Intensive care unit stay and inhospital stay were almost similar in both the groups. All-cause mortality was significantly high in the SAC group [Table 4].
Table 3: Postoperative findings

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Table 4: Comparison of hospital mortality between double-arterial cannulation and single-arterial cannulation

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  Discussion Top

AAD is less common but a complex cardiovascular pathology which needs to be addressed immediately. Perioperative mortality is high even in higher centers with advance techniques and perioperative management. Most of the time complete cardiopulmonary arrest (DHCA) is induced to obtain bloodless field and allow surgery on major blood vessels. Hypothermia applied causes depression of the cellular metabolism, thus protecting organs from ischemia, but at the same time, central nervous system (CNS) being very volatile is susceptible to deleterious effects of ischemia. During DHCA, various strategies are applied for monitoring of CNS such as electroencephalogram, somatosensory-evoked potential, near-infrared spectroscopy, and sjV02. Additionally, pharmacological neuroprotection is also feasible with this technique. One of the prime factors in DHCA is time saved which favors its usage. Ischemia time is of utmost importance, hence the surgery is performed hastily which again at times increases the chances of complications.

All these abovementioned drawbacks of DHCA can be avoided by the dual cannulation strategy. Continuous antegrade cerebral blood flow is initiated which ensures the neuroprotection beyond doubt and various neuromonitoring devices can be avoided. The perfusion of other vital organs and lower limbs can be ensured through the femoral cannulation. Thus, the whole body is adequately perfused throughout the CPB duration while at the same time ensuring a clear and bloodless field for the surgery. Hence, to prevent end-organ malperfusion, appropriate institution and maintenance of CPB during surgery is required.[6] Furthermore, this removes the critical time constraint associated with DHCA, thus less mishaps. The patient has a smoother postoperative course owing to lack of ischemia, thus morbidity reduces.

Arch surgeries are done till date in DHCA in almost every center in the world. If there is any safer and equally effective option available, then it should be surely explored and taken advantage. This dual cannulation technique is exactly such a thing which removed the hazards of DHCA while giving a perfect surgical field for anastomosis without critical time constraints. The need for DHCA can be obviated by giving continuous cerebral perfusion during moderate hypothermia, DAC strategy using both right axillary artery and femoral artery can be effectively used to provide both anterograde cerebral perfusion and retrograde perfusion to vital abdominal organs and lower limbs. This technique provides reliable circulatory support, but a limited number of publications with less number of cases are available.[7] In our study we used DAC technique in 34 patients and nearly 88% of patients survived and were available for short-term follow-up.

As more number of centers performing complex aortic surgery strategies to protect cerebral function continues to evolve, the question arises whether DAC technique can be used in all spectrum of AAD irrespective of extent of dissection flap extending into abdominal and lower limb arteries causing luminal compromise. Kusadokoro et al. reported that they preferred using DAC technique in patients who had true lumen stenosis due to dissection flap causing malperfusion in lower limb.[8] Zhang et al. also noted that DAC will not increase the surgical risks compared to RAC, but can reduce the incidence of postoperative renal dysfunction.[9] In our study, we used DAC technique in patients who had significant pressure difference between left femoral and right radial arterial pressures transduced during perioperative period.

As demonstrated by Lin et al.,[2] inhospital mortality, incidence of stroke, and malperfusion were lower in patients who underwent surgery using DAC technique, and when this was compared with patients undergoing surgery by SAC technique in the study group, it showed statistically significant. Three-year survival rate was also better in DAC group patients. In our study also, we noticed that there was no inhospital mortality and lower other complications in the DAC group.

In our study, the patients in the DAC group had more urine volume as compared to those in the SAC group and this indicates that both forward and reverse perfusion increases renal blood flow and has better preservation for the kidney function during AAD surgery. In our study group, none of the patients operated using DAC had to undergo hemodialysis whereas one patient underwent hemodialysis for AKI. Based on what we found in this study, we thought that DAC could reduce the incidence of AKI by providing better kidney perfusion.

  Conclusion Top

Cannulation strategy represents a critical choice that may play a crucial role in determining operative outcomes in AAD surgery. This dual cannulation strategy for arch surgery is revolutionary to serve its purpose by providing proper antegrade cerebral flow along with distal body perfusion at the same time providing a great surgical field to work on. Techniques like these should be adopted and explored in different scenarios for its optimal usage.

AAD surgery can be performed safely by providing reliable arterial flow and obtaining adequate tissue perfusion in the whole body, especially when true lumen size is compromised by dissection flap. When performed at an experienced institution, DAC may yield satisfactory short- and mid-term outcomes. DAC is safe for Type A aortic dissection operation, which has better perioperative and mid-term outcomes compared to DHCA/SAC.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Ethical approval

As this was a retrospective analysis of the surgical outcomes of the surgical technique, prior ethics committee approval was not taken.

Authors' contributions

Dr. Pravin Nayak: Conceptualisation, Design, Acquisition, Draft; Dr. Archit Patel: Draft, Design, Interpretation; Dr. Rahul Singh: Literature review, data analysis; Dr. Chirag Doshi: Design, draft.

  References Top

Garg V, Peterson MD, Chu MW, Ouzounian M, MacArthur RG, Bozinovski J, et al. Axillary versus innominate artery cannulation for antegrade cerebral perfusion in aortic surgery: Design of the Aortic Surgery Cerebral Protection Evaluation (ACE) CardioLink-3 randomised trial. BMJ Open 2017;7:e014491.  Back to cited text no. 1
Lin CY, Tseng CN, Lee HA, Ho HT, Tsai FC. Double arterial cannulation strategy for acute type A aortic dissection repair: A 10-year single-institution experience. PLoS One 2019;14:e0211900.  Back to cited text no. 2
Krüger T, Weigang E, Hoffmann I, Blettner M, Aebert H, GERAADA Investigators. Cerebral protection during surgery for acute aortic dissection type A: Results of the German Registry for Acute Aortic Dissection Type A (GERAADA). Circulation 2011;124:434-43.  Back to cited text no. 3
Snyderman C, Kassam A, Carrau R, Mintz A, Gardner P, Prevedello DM. Acquisition of surgical skills for endonasal skull base surgery: A training program. Laryngoscope 2007;117:699-705.  Back to cited text no. 4
Locketz GD, Lui JT, Chan S, Salisbury K, Dort JC, Youngblood P, et al. Anatomy-specific virtual reality simulation in temporal bone dissection: Perceived utility and impact on surgeon confidence. Otolaryngol Head Neck Surg 2017;156:1142-9.  Back to cited text no. 5
Hessel EA 2nd. What's new in cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2019;33:2296-326.  Back to cited text no. 6
Gammie JS, Landree B, Griffith BP. Integrated cerebral protection: Combined antegrade and retrograde cerebral perfusion during deep hypothermic circulatory arrest. Innovations (Phila) 2010;5:355-8.  Back to cited text no. 7
Kusadokoro S, Kimura N, Double arterial cannulation: a classical yet useful cannulation strategy—comment on cannulation strategy in frozen elephant trunk for type A aortic dissection: double arterial cannulation approach, Euro J CardioThorac Sur 2022; 62, ezac231.  Back to cited text no. 8
Zhang H, Xie W, Lu Y, Pan T, Zhou Q, Xue Y, et al. Double arterial cannulation versus right axillary artery cannulation for acute type A aortic dissection: A retrospective study. J Cardiothorac Surg 2021;16:326.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]


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