Strategy Of Arterial Cannulation And Selective Perfusion As The Key To Success In Aortic Surgery
Domenico Calcaterra, MD, PhD1, Rachel Nygaard, PhD2, Kevin Harris, MD1, Joseph Turek, MD, PhD3, Mohammad Bashir, MD4, Yousuf Mahomed, MD5.
1Minneapolis Heart Institute at Abbott Northwestern, Minneapolis, MN, USA, 2Hennepin Medical Center, Minneapolis, MN, USA, 3Duke University Medical Center, Durham, NC, USA, 4University of Iowa Hospital and Clinics, Iowa City, IA, USA, 5Indiana University School of Medicine, Indianapolis, IN, USA.
Background: the success of surgical treatment of aortic pathologies relies on the application of an appropriate cannulation strategy ensuring adequate body perfusion and satisfactory organ protection during repair. Methods: in a series of 212 consecutive patients undergoing elective and emergent aortic replacement by a single surgeon from January 2009 to November 2017, 165 required peripheral arterial cannulation. Results: there were 71 right axillary, 82 right femoral and 12 left common carotid cannulations. One hundred fifty-two operations involved the proximal aorta (PA) (root/ascending/arch) and 60 the thoracoabdominal aorta (TAA). Sixty-four of these were performed emergently for acute aortic syndrome (59 PA replacements and 5 TAA replacements). Right axillary artery cannulation was utilized in 71 PA operations. Femoral arterial cannulation was utilized in all TAA replacements and 22 PA replacements. In 9 of these, femoral arterial cannulation was paired with right axillary cannulation. In 12 cases of TAA replacements femoral cannulation was paired with left common carotid cannulation (fig. 1). At the beginning of our experience with right axillary cannulation, an 8 mm Dacron graft was sewn to the axillary artery in an end-to-side fashion, nonetheless the technique was subsequently modified advancing an aortic cannula through the Dacron graft to optimize flow-dynamics and minimize bleeding (fig.1). Left common carotid artery cannulation has been added to femoral arterial cannulation in the most recent 12 cases of TAA replacement using full cardiopulmonary by-pass to avoid retrograde aortic blood flow and allow selective cerebral perfusion during circulatory arrest (fig. 1). We had an overall thirty-day mortality of 3.9 % with PA replacements and 4.8 % with TAA replacements, and a low incidence of stroke in the PA replacement group (2.6 %) and paraplegia in the TAA replacement group (8.3 %). Conclusions: the application of a versatile arterial cannulation strategy aimed at maintaining appropriate body perfusion and adequate organ protection offers excellent results in aortic surgery, with low mortality and low incidence of major complications. In our experience, the introduction of novel modifications of the arterial cannulation techniques and the use of multiple arterial inflow sites were the key to improve outcomes in aortic surgery procedures. 
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