Femoral artery cannulation has been used for cardiopulmonary

Femoral Cannulation is Safe for Type A Dissection Repair Daniel S. Fusco, MD, Richard K. Shaw, MD, Maryann Tranquilli, RN, Gary S. Kopf, MD, and John A. Elefteriades, MD Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut Background. Recently, surgeons have embraced axillary artery cannulation for type A aortic dissection repair out of concern for malperfusion phenomena with traditional femoral artery cannulation. My colleagues and I sought to determine whether these concerns are justified. Methods. Records of 86 consecutive patients (51 men and 35 women; age, 30 to 86 years; mean, 62 years) undergoing surgical repair for acute type A dissection were reviewed. Cannulation site, specific operative repair, and complications related to cannulation were noted. Results. Seventy-nine cannulations were performed in the femoral artery (47 left, 23 right, and 9 unspecified), 3 in the axillary artery (1 left and 2 right), and 4 in the ascending aorta or arch. Deep hypothermic arrest was used in 64 operations. Seven involved re-sternotomy. Seventy patients had supracoronary grafts (2 with valve replacement and 10 with valve resuspension), and 16 underwent aortic root replacement. Fourteen patients were in shock from cardiac tamponade. Eighty patients survived the operation, and 71 were hospital survivors. Malperfusion on initiation of cardiopulmonary bypass was noted in 3 patients. In 1, the original cannulation site was the ascending aorta, and the cannula was moved to the femoral artery for correction. In 2, the original cannulation site was the femoral artery, and the cannula was moved to the ascending aorta. Malperfusion on clamping of the aorta or on resumption of aortic flow was noted in no patient. Postoperative ischemia of any vascular bed was noted locally only in 3 (cannulated) lower extremities. Conclusions. Straight femoral cannulation for all phases of type A dissection repair is appropriate and yields excellent clinical results. The anticipated malperfusion events are actually rare (2 of 79 with femoral artery cannulation, or 2.5%). (Ann Thorac Surg 2004;78:1285 9) 2004 by The Society of Thoracic Surgeons Femoral artery cannulation has been used for cardiopulmonary bypass grafting since the 1950s [1], but it was eventually replaced by cannulation of the ascending aorta. However, the femoral artery has continued to be used in cases in which emergent establishment of cardiopulmonary bypass is anticipated or when the ascending aorta is not suitable, as in acute ascending aortic dissection. Ascending aortic dissection (Stanford type A or De- Bakey type I or II) is a surgical emergency with a high natural morbidity and mortality [2 4]. Its incidence is 5.2 per million per year [5] twice the rate of ruptured abdominal aortic aneurysm. The treatment has traditionally been repair with right atrial-femoral bypass grafting. However, concern for intraoperative malperfusion syndrome [6 9], reported to be as high as 13% [10], has caused surgeons to search for alternative sites for cannulation [10 17]. Published experience with axillary cannulation for acute ascending dissection is summarized in Table 1. Each series is modest in terms of the number of patients treated with axillary cannulation. There is a growing perception that femoral cannulation Accepted for publication April 20, 2004. Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26 28, 2004. Address reprint requests to Dr Elefteriades, 121 FMB, 333 Cedar St, New Haven, CT 06510; e-mail: john.elefteriades@yale.edu. is not appropriate for repair of acute type A dissection. My colleagues and I wished to investigate this issue by drawing on clinical experience with this entity at our institution. We reviewed our last 86 cases of acute type A aortic dissection. Our preferred arterial cannulation site for repair of acute ascending dissection is the femoral artery. These cases provide an opportunity to evaluate the merits or demerits of this approach specifically regarding the potential for intraoperative malperfusion syndrome. The aim of this study was to determine the safety of femoral cannulation for repair of acute type A aortic dissection. This is not intended to be a comparative study of different methods of cannulation, but rather a specific look at a large experience with femoral cannulation, with an eye toward identifying any malperfusion complications of this approach. Material and Methods Medical records, computer records, operative notes, and discharge summaries were reviewed for all patients with an acute ascending aortic dissection who underwent This article has been selected for the open discussion forum on the CTSNet Web site: http://www.ctsnet.org.discuss 2004 by The Society of Thoracic Surgeons 0003-4975/04/$30.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2004.04.072

1286 FUSCO ET AL Ann Thorac Surg FEMORAL CANNULATION IS SAFE FOR TYPE A DISSECTION REPAIR 2004;78:1285 9 Table 1. Published Experience With Axillary Artery Cannulation in Acute Ascending Dissections Study operation from 1981 to 2003. (Seventy-eight percent of these patients were treated after 1997.) The cannulation site, specific operative repair, and complications related to cannulation were noted, as was the overall clinical outcome. Specific attention was paid to intraoperative malperfusion syndromes and the need to change the cannulation site. Our preferred technique involves sequentially 1. Femoral artery cannulation and perfusion 2. Aortic cross-clamping 3. Performance of the proximal anastomosis 4. Unclamping of the aorta with the patient under deep hypothermic arrest 5. Performance of an open distal anastomosis 6. Resumption of perfusion 7. Rewarming with the original femoral cannula Thus, the femoral cannula is used for the entire procedure, without elective replacement to the constructed graft. We do routinely inspect for malperfusion initially after establishing cardiopulmonary bypass, by measuring the radial artery pressure, checking the head vessels for forward flow by transesophageal echocardiogram, and palpating the aorta. These checks are repeated again after the aorta is cross-clamped. Results No. Patients Stroke (%) Survival (%) Sabik [15] 8 0? Baribeau [22] 17 6 70 Neri [10] 22 0 91 Whitlark [14] 13 6 92 Schachner [12] 16 0 81 Yavuz [17] 27 4 93 Sinclair [11] 11?? Pasic [16] 20 5 95 Eighty-six patients (51 men and 35 women) ranging from age 30 to 86 years (mean, 62 years) were identified with acute ascending aortic dissection. Fourteen presented in tamponade, 62 with chest pain, 28 with back pain, 11 with Table 3. Postoperative Complications Complication No. Patients Stroke 7 Renal failure 7 Reexploration (bleeding) 4 Tracheostomy 3 Fasciotomy 3 Groin infection 2 Pneumonia 2 Aortic insufficiency 1 GI hemorrhage 1 Diaphragm paralysis 1 HIT 1 Sepsis 1 GI gastrointestinal; HIT heparin-induced thrombocytopenia. abdominal pain, 11 with shortness of breath, and 3 with syncope. Seventy-nine cannulations were performed in the femoral artery (47 left, 23 right, and 9 unspecified), 3 in the axillary artery (1 left and 2 right), and 4 in the ascending aorta or arch. Nonfemoral cannulation sites were chosen because of known ileofemoral disease or disease of the descending or thoracoabdominal aorta. Deep hypothermic arrest was used in 64 operations. Seven operations involved re-sternotomy. Seventy patients had supracoronary grafts with hemiarch repair (2 with aortic valve replacement and 10 with aortic valve resuspension), and 16 underwent aortic root replacement with a composite graft. Eighty patients survived the operation, and 71 of these were hospital survivors. Malperfusion on initiation of cardiopulmonary bypass was noted in 3 patients (Table 2). In the first, the ascending aorta had been cannulated directly through the dissection. The cannulation site was changed to the right femoral artery, and the case continued. The patient died in the operating room of end-organ ischemia. In the second patient, the left femoral artery was initially used for cannulation. The cannula was moved to the right femoral artery after the perfusion team reported low pump volumes and pressures despite an empty heart. These difficulties with perfusion continued, and the ascending aorta was eventually cannulated through the dissection. No improvement resulted, and the patient died in the operating room. At autopsy the patient was found to have a concomitant abdominal aortic aneurysm, Table 2. Malperfusion Events Initial Cannulation Site Event Result Ascending aorta Left femoral artery Left femoral artery AAA abdominal aortic aneurysm; False lumen cannulated. Site changed to right femoral artery Poor venous return. Site changed to right femoral artery High back pressure. Site changed to ascending aorta OR operating room. Died in OR of end-organ ischemia Died in OR from ruptured AAA No neurologic recovery after operation

Ann Thorac Surg FUSCO ET AL 2004;78:1285 9 FEMORAL CANNULATION IS SAFE FOR TYPE A DISSECTION REPAIR 1287 Fig 1. Flow diagram of patients with perioperative cerebrovascular accident (CVA). Four of the 8 patients were severely unstable before arrival in the operating room, and neurologic dysfunction was expected. Three strokes developed late after operation and cannot be attributed to intraoperative malperfusion or embolization. (CPR cardiopulmonary resuscitation.) which had ruptured during the case, in addition to the type A dissection. We counted this as a malperfusion case, although it seems to be a complication related to the abdominal aortic aneurysm. In the third case, the left femoral artery was used for cannulation. High back pressure was noted after cardiopulmonary bypass was established. The ascending aorta was then cannulated directly, and cardiopulmonary bypass was reestablished. The patient survived the operating room but eventually died from complications of a stroke. Thus, the adverse event rate in patients initially cannulated in the femoral artery was only 2 of 79, or 2.5%. The third malperfusion-type event in this experience occurred after aortic not femoral cannulation. All 77 other patients underwent surgical replacement of the aorta with femoral cannulation and perfusion with no perfusion abnormalities. Malperfusion on clamping of the aorta or on resumption of aortic flow was not seen in any patient. Postoperative ischemia of any vascular bed was noted in only 3 (cannulated) lower extremities. These were all believed to be local phenomena of the lower extremity vascular system, caused by cannulation and suture repair of the femoral arteriotomy. Other postoperative complications are shown in Table 3. In case any malperfusion events went unappreciated during the operation, we retrospectively scrutinized the case records of all patients who died or had strokes, looking for any possible relationship to general malperfusion not recognized during or after operation. Figures 1 and 2 present a classification of all deaths and strokes. As can be seen in these figures and the accompanying legends, even retrospectively we could not attribute these adverse outcomes to unrecognized malperfusion phenomena. Comment Type A aortic dissection has a high natural morbidity and mortality rate. No cannulation technique can completely avoid the risk of a malperfusion vascular event. In our experience, these events are rare, as demonstrated by these 86 cases. Review of our operative experience with femoral cannulation for repair of acute type A aortic dissection reveals malperfusion in only 2.5% of cases. We have no quarrel with axillary cannulation for acute type A dissection repair. We believe that the data presented in this study indicate that the traditional approach of femoral cannulation is indeed a safe one, with years upon years of worldwide application. We point out that the total experience recorded in the literature for axillary cannulation for type A repair (Table 1) is rather scant and that the published articles do not confirm the superiority of axillary over femoral cannulation. We believe strongly in the use of axillary artery cannulation for the repair of arteriosclerotic ascending and arch aneurysms, because these patients often have extensive atheromata that can be embolized to the brain. In contradistinction, it is our experience that patients with acute ascending dissection rarely manifest arteriosclerosis or plaque in the descending (or ascending) aorta. Our experience in this regard is supported by published literature indicating less common arteriosclerosis in dissection patients [18], as well as by studies pointing to a molecular basis for such a trend [19 21]. Of course, some type A patients will on occasion manifest thoracoabdominal arteriosclerosis, which may predispose to retrograde embolization during femoral perfusion. One can point out that in our experience we may have selected such individuals as the few type A patients in whom we did apply axillary cannulation. We see this not as a demerit of the femoral perfusion technique, but rather as a demonstration that clinical judgment and flexibility in the selection of perfusion technique are warranted. Fig 2. The breakdown of the causes of death indicates that in 2 cases, a relationship to the mode of cannulation and perfusion is possible. These are the 2 cases indicated in the chart by femoral cannulation. In the other cases, no direct relationship to perfusion was apparent either in real time during clinical care or on subsequent detailed review. (CVA cerebrovascular accident; ICU intensive care unit; OR operating room.)

1288 FUSCO ET AL Ann Thorac Surg FEMORAL CANNULATION IS SAFE FOR TYPE A DISSECTION REPAIR 2004;78:1285 9 Femoral cannulation continues to be a safe technique for establishing cardiopulmonary bypass for the repair of acute ascending aortic dissections. References 1. Lillehei CW, Cardozo RH. Use of median sternotomy with femoral artery cannulation in open cardiac surgery. Surg Gynecol Obstet 1959;108:707 14. 2. DeBakey ME, McCollum CH, Crawford ES, et al. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982;92:1118 34. 3. Cambria RP, Brewster DC, Gertler J, et al. Vascular complications associated with spontaneous aortic dissection. J Vasc Surg 1988;7:199 209. 4. Goldstein LJ, Davies R, Rizzo JA, et al. Vascular complications associated with spontaneous aortic dissection. J Thorac Cardiovasc Surg 2001;122:935 45. 5. Baue AE, Geha A, Hammond GL, et al. Glenn s thoracic and cardiovascular surgery. 6th ed, Vol 2. Stamford, CT: Appleton & Lange, 1996:2273 4. 6. Laas J, Heinemann M, Schaefers HJ, et al. Management of thoracoabdominal malperfusion in aortic dissection. Circulation 1991;84(5 Suppl 3):20 4. 7. Van Arsdell GS, David TE, Butan J. Autopsies in acute type A aortic dissection: surgical implications. Circulation 1998; 98(19 Suppl 2):299 302. 8. Pappas G, Starzl TE. Retrograde false channel perfusion: a complication of cardiopulmonary bypass during repair of dissecting aneurysms. Ann Thorac Surg 1970;9:263 6. 9. Ergin MA, Phillips RA, Galla JD, et al. Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 1994;57:820 5. 10. Neri E, Massetti M, Capannini G, et al. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999;118:324 9. 11. Sinclair MC, Singer RL, Manley NJ, Montesano RM. Cannulation of the axillary artery for cardiopulmonary bypass: safeguards and pitfalls. Ann Thorac Surg 2003;75:931 4. 12. Schachner T, Vertacnik K, Laufer G, Bonatti J. Axillary artery cannulation in surgery of the ascending aorta and the aortic arch. Eur J Cardiothorac Surg 2002;22:445 7. 13. Banbury MK, Cosgrove DM. Arterial cannulation of the innominate artery. Ann Thorac Surg 2000;69:957. 14. Whitlark JD, Goldman SM, Sutter FP. Axillary artery cannulation in acute ascending aortic dissections. Ann Thorac Surg 2000;69:1127 9. 15. Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885 91. 16. Pasic M, Schubel J, Bauer M, et al. Cannulation of the right axillary artery for surgery of acute type A aortic dissection. Eur J Cardiothorac Surg 2003;24:231 5; discussion 235 6. 17. Yavuz S, Göncü MT, Türk T, et al. Axillary artery cannulation for arterial inflow in patients with acute dissection of the ascending aorta. Eur J Cardiothorac Surg 2002;22:313 5. 18. Kojima S, Suwa S, Fujiwara Y, et al. Incidence and severity of coronary artery disease in patients with acute aortic dissection: comparison with abdominal aortic aneurysm and arteriosclerosis obliterans. J Cardiol 2001;37:165 71. 19. Silence J, Collen D, Lijnen HR. Reduced atherosclerotic plaque but enhanced aneurysm formation in mice with inactivation of the tissue inhibitor metalloproteinase-1. Circ Res 2002;90:836 7. 20. Nakai K, Itoh C, Kawazoe K, et al. Concentration of soluble vascular cell adhesion molecule-1 (VCAM-1) correlated with expression of VCAM-1 mrna in the human atherosclerotic aorta. Coron Artery Dis 1995;6:497 502. 21. Agmon Y, Khandheria BK, Meissner I, et al. Is aortic dilatation an atherosclerosis-related process? J Am Coll Cardiol 2003;42:1076 83. 22. Baribeau YR, Westbrook BM, Charlesworth DC. Axillary cannulation: First choice for extra-aortic cannulation and brain protection (letter). J Thorac Cardiovasc Surg 1999;118: 1153 4. DISCUSSION DR JOHN FLEGE (Cincinnati, OH): Have you considered cannulating the ascending aorta transventricularly, as reported by us and others? This virtually ensures that you will not have malperfusion syndrome, it is quick to institute, and as far as our experience goes, we have had no appreciable complications with it. DR FUSCO: Thank you for emphasizing the transventricular cannulation alternative. We applied that technique early in our experience, with mixed results. Perfusion was achieved, but we did encounter problems with inadequate sealing of the aortic valve around the cannula and with the large opening remaining in the left ventricular apex after decannulation. Although we did not use the transventricular option in the series of patients reported here, we believe that it is important to be aware of this option. DR JOHN W. HAMMON (Winston-Salem, NC): I was intrigued by your remark when you said that no cannulation technique can guarantee the absence of malperfusion, so would it not also be very reasonable to monitor patients, such as is being done at the University of Pennsylvania and elsewhere, with electroencephalogram and other techniques to make sure that cerebral perfusion is occurring? DR FUSCO: We believe that it is crucially important, as you point out, Dr Hammon, to confirm perfusion to the head. We do this by 2 means: palpation of the aortic arch to confirm proper pressurization, and direct visualization of forward flow into the great vessels by transesophageal echocardiography. In terms of confirming the adequacy of deep hypothermia, the electroencephalogram can indeed be useful. Bavaria s data show that after 30 minutes of cooling, approximately 60% of patients achieve electrical silence, and by 45 minutes almost all will be flat-lined. At our institution we simply wait for several minutes equilibration at a core (urinary bladder) temperature of 18 C. DR RAUL GARCIA-RINALDI (Mayaguez, Puerto Rico): It has been our impression that the side of the true lumen usually has an absent pulse, whereas the artery that has the best pulse is the one that feeds into the false lumen. Surgeons who do a lot of this type of surgery recommend perfusing into the leg with the worst pulse. Can you comment on that, please? DR FUSCO: That has not been our approach. We choose the side with the better pulse. If that side is found to be dissected, we go to the contralateral side. If both sides are dissected, we exercise great care to make certain that our cannula is placed into the true lumen. In the current era of 3-dimensional imaging, the computed tomography scan will often point to the better (or, less involved) side for cannulation. DR SHINICHI TAKAMOTO (Tokyo, Japan): I agree with your conclusion. I am doing this cannulation of the femoral artery for

Ann Thorac Surg FUSCO ET AL 2004;78:1285 9 FEMORAL CANNULATION IS SAFE FOR TYPE A DISSECTION REPAIR 1289 acute dissection. But you mentioned that you anastomose the proximal site first, clamping the ascending aorta in the proximal anastomosis first and subsequently performing the distal anastomosis. I have experienced, after clamping the ascending aorta, that the reentry from the femoral cannulation site is closed because the big entry is closed by the clamping. In such a case, the false lumen is dilated and then causes malperfusion. So I think that in femoral cannulation, the distal anastomosis should be performed during deep hypothermia. What do you think about that? DR FUSCO: The anatomic pathology of aortic dissection can be very complex 3-dimensionally. Theoretically, clamping the aorta after initiation of perfusion may cause pressurization of the false lumen. We wish to emphasize from this series that malperfusion is extremely rare despite femoral perfusion and clamping of the ascending aorta. Although this is a concern, it simply has not been problematic in our experience. We perform the proximal anastomosis with the clamp on; then we perform an open distal anastomosis with the patient under deep hypothermic circulatory arrest. DR ADIB H. SABBAGH (Tucson, AZ): Did any of these patients have Marfan s syndrome, and do you change your approach with Marfan s patients? DR FUSCO: We do not change our approach in Marfan s patients. Approximately 10% of our patients have Marfan s disease. We cannulate femorally and replace the entire ascending aorta and aortic root. Notice From the American Board of Thoracic Surgery The 2004 Part I (written) examination will be held on Monday, December 6, 2004. It is planned that the examination will be given at multiple sites throughout the United States using an electronic format. The closing date for registration was August 1, 2004. Those wishing to be considered for examination must apply online at www.abts.org. To be admissible to the Part II (oral) examination, a candidate must have successfully completed the Part I (written) examination. A candidate applying for admission to the certifying examination must fulfill all the requirements of the Board in force at the time the application is received. Please address all communications to the American Board of Thoracic Surgery, 633 N St. Clair St, Suite 2320, Chicago, IL 60611; telephone: (312) 202-5900; fax: (312) 202-5960; e-mail: info@abts.org. 2004 by The Society of Thoracic Surgeons Ann Thorac Surg 2004;78:1289 0003-4975/04/$30.00 Published by Elsevier Inc