doi:10.1510/icvts.2009.230409 Summary Interactive CardioVascular and Thoracic Surgery 10 (2010) 797 802 www.icvts.org Best evidence topic - Aortic and aneurysmal Which (ascending aortic or peripheral arterial ) is better for acute type A aortic surgery? Kaushal K. Tiwari *, Michele Murzi, Stefano Bevilacqua, Mattia Glauber a,b, b b b a Sant Anna School for Higher Studies, Pisa, Italy b Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, 54100 Massa, Italy Received 9 December 2009; received in revised form 25 January 2010; accepted 26 January 2010 Work in Editorial New Ideas Progress Report Protocol Institutional Report A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was Which (ascending aortic or peripheral arterial ) is better for acute type A aortic surgery? Altogether 393 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Femoral artery has the highest rate of mortality, stroke rate and other complications including retrograde cerebral embolization, organ malperfusion and perfusion of the false lumen. Five out of 14 papers were found to be reporting in favour of axillary (or subclavian) artery over femoral artery. In a total of 1829 patients evaluated in these studies, 1068 patients demonstrated a significantly lower complication rate with axillary artery than femoral artery. Some of the larger studies showed femoral artery has higher mortality and stroke rates ranging from 6.5% to 40% and 3% to 17%, respectively. Meanwhile, mortality and stroke rates were ranging from 3% to 8.6% and 1.75% to 4%, respectively, in the favour of axillary artery. A total of seven studies evaluated direct aortic for the establishment of cardiopulmonary bypass (CPB). They demonstrated mortality and stroke rates from 0% to 15% and 3.8% to 21%, respectively. Central has promising results with a lower mortality rate but a higher stroke rate. Direct of the true lumen is a promising method for quick and easy establishment of CPB. Axillary artery with a side graft, although it takes more time to construct, is proven to be safe and straightforward, with fewer local and systemic complications including lower mortality and neurological complications. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. ESCVS Article Proposal for Bailout Procedure Negative Results Follow-up Paper Keywords: Type A aortic ; Cannulation 1. Introduction 4. Search strategy State-of-the-art A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS w1x. 2. Three-part question In wpatients, undergoing surgery, for acute type A aortic x is wcentral ascending aorta x better than wperipheral arterial x to reduce wmorbidity, stroke rate and mortalityx? 3. Clinical scenario You are planning an emergency repair of a type A aortic. Your usual technique is to use femoral arterial, but the last time you used this technique the patient suffered a postoperative stroke. You wonder whether and alternative method of would reduce the chance of this complication. *Corresponding author. Tel.: q39 0585 493604; fax: q39 0585 493614. E-mail address: drkaushalkt@yahoo.com (K.K. Tiwari). 2010 Published by European Association for Cardio-Thoracic Surgery The search was performed using http:yyhighwire. stanford.edu interface. The search terms used were: acute type A aortic, axillary, femoral and aortic. 5. Search outcome Three hundred and ninety-three papers were found using the reported search. From these 14 papers were identified that provided the best evidence to answer the question. These are presented in Table 1. 6. Results Recently, Kamiya et al. w2x analysed the results of 235 patients undergoing surgery for acute type A aortic using direct ascending aortic and percutaneous femoral artery. These authors showed that ascending aortic has lower mortality than femoral artery. However, there were no signif- Best Evidence Topic Nomenclature Historical Pages Brief Case Report Communication
798 K.K. Tiwari et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 797 802 Table 1 Best evidence papers Author, date and Patient group Outcomes Key results Comments country, Study type (level of evidence) Kamiya et al., (2009), 235 patients from January Mortality (30 days) 14% Aortic group Lower mortality in aortic Circulation, Germany, 1998 to September 2007 23% Femoral group group w2x underwent: Direct ascending Ao Incidence of stroke 4.9% Aortic group Both ascending aortic and femoral Retrospective cohort (ns82) 4.5% Femoral group artery is accepted Femoral artery mean of (ns153) Long-term survival 5 years: 65% Aortic group Site of should be 64% Femoral group chosen depending upon individual patients status Khaladj et al., (2008), 122 patients underwent Mortality (30 days) 15% Central by Seldinger Eur J Cardiothorac central ascending aortic technique is safe, quick, straight Surg, Germany, w3x from November Incidence of stroke 12% forward and easy to established 1999 to February 2006 Retrospective cohort using the Seldinger technique Reece et al., (2007), 70 patients from July 1996 Mortality (30 days) 0% Central group The aortic cannula was held in J Thorac Cardiovasc to July 2005 underwent: 17% Peripheral place by hand during cooling, Surg, USA, w4x Central ascending aortic group which make this procedure little using the uncomfortable Retrospective cohort Seldinger technique Incidence of stroke 21% Central group (ns24) 28% Peripheral Peripheral (femoralq group axillary) (ns46) by arterial cutdown Reuthebuch et al., From January 1997 to Mortality 8.6% Subclavian Unilateral subclavian artery (2004), Eur J January 2003, 122 patients group approach provides antegrade Cardiothorac Surg, underwent surgery for 23.3% Femoral cerebral perfusion leading to Switzerland, w5x acute type A aortic group remarkable brain protection Retrospective cohort Subclavian group, SG Prolonged 1.75% Subclavian (ns62), postoperative group Femoral group, FG neurological 17.4% Femoral (ns60) dysfunction group Both s are carried out by direct exposure and Renal failure 11% Subclavian arterial cutdown group 23% Femoral group Sabik et al., (2004), From 1993 to January Mortality 8% for entire cohort Low-risk of malperfusion during Ann Thorac Surg, 2001, 391 patients 7.6% Direct axillary artery USA, w6x underwent axillary artery (direct or with a side graft) 8.6% With side graft Most common complication of Observational clinical for different axillary artery is case-control study cardiac surgical procedure. axillary artery and brachial plexus (level 3b) Among these 85 patients Local complication 2.8% Direct injury operated for type A aortic (brachial plexus injury) 0.5% With side graft Complication can be reduced with side graft Aortic 1.4% Direct 0% With side graft Svensson et al., 1336 patients underwent Mortality 7.0% AxqSG Axillary artery with (2004), Ann Thorac complex cardiac surgical 7.8% Ax no SG side graft on it allows safer Surg, USA, w7x procedure using different 7.0% Aorta complex cardiac operations sites: 11% Femoral Cohort study Aorta 471, 12% Innominate This study analysed not only (level 2b) Femoral 374, type A aortic patients AxqSG 299, Stroke 4.0% AxqSG Ax no SG 167, 7.8% Ax no SG External iliac 1, 6.4% Aorta (Continued on next page)
K.K. Tiwari et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 797 802 799 Table 1 (Continued) Author, date and Patient group Outcomes Key results Comments country, Study type (level of evidence) Innominate 24 6.7% Femoral 4.2% Innominate Chiappini et al., From 1976 to 2003, 487 Mortality 22% Major brain damage, visceral (2005), Eur Heart J, patients were operated on ischaemia and ascending aorta Italy, The for acute type A aortic Stroke 18.2% rupture were main causes of death Netherlands, w8x. Majority (98.2%) of them were Survival 94.9"1.2% 5 years Retrospective cohort operated using femoral 88.1"2.6% 10 years Fusco et al., (2004), Total 86 patients Death 12.9% Only two deaths (1.5%) were Ann Thorac Surg, underwent surgery for directly related to femoral USA, w9x type A Ao, out Stroke 6%. Out of seven patients of which seventy-nine having CVA, four were severely Retrospective cohort (67.9%) patients were unstable before arrival in cannulated through operating room femoral artery from 1981 to 2003 Conzelmann et al., Between April 2004 and Mortality 0% Direct true lumen is (2009), Ann Thorac August 2007, 29 patients technically feasible in all patients Surg, Germany, w10x underwent surgery for Ao Neurological 21% by direct true complications Limitation: small number of Retrospective cohort lumen after patient population opening of the ascending aorta Moizumi et al., From May 1992 to July Mortality 7.2% Axillary artery Absence of axillary artery (2005), Ann Thorac 2004, 106 patients group perfusion is shown to be an Surg, Japan, w11x underwent surgery for acute 30% Femoral artery independent intraoperative type A aortic group predictor of hospital death Retrospective cohort using: Femoral artery (ns37) Axillary artery (ns69) Inoue et al., (2007), Thirty-two patients with Mortality 3.1% Femoral has been Eur J Cardiothorac type A Ao carried out to establish CPB, Surg, Japan, w12x underwent surgery by Neurological 6.3% which is time-consuming direct ascending aortic complication Retrospective cohort using Seldinger Direct ascending aorta technique in addition to by Seldinger technique is easy femoral artery to establish CPB No complication related to extension of the or false lumen Nouraei et al., (2007), Forty-nine patients with Hospital mortality Femoral 40% Lower incidence of re-operation in Asian Cardiovasc acute type A aortic Subclavian 10% subclavian group (odds ratio 1.7; Thorac Ann, UK, w13x were studied 95% CI) between 1999 and 2004. Retrospective cohort CPB was established using: Univariate analysis showed Femoral artery (ns29) femoral as significant Subclavian artery (ns20) predictor of neurological deficit and hospital death Best Evidence Topic Etz et al., (2008), From 1990 to 2005, 869 Hospital mortality All cause Axillary artery has Ann Thorac Surg, patients undergoing Aorta 5.1% proved to be the preferred USA, w14x complex aortic surgery Femoral 6.5% site in complex aortic surgery were included out of which Axillary 3.3% Retrospective cohort 171 patient were with Chronic aortic Axillary artery chronic and acute conferred a significant advantage. Patients were Aorta 11% in averting an adverse outcome divided according to site Femoral 9% compared with other of as followed: Axillary 12% Aortic 157 Acute aortic Femoral 261 (Continued on next page)
800 K.K. Tiwari et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 797 802 Table 1 (Continued) Author, date and Patient group Outcomes Key results Comments country, Study type (level of evidence) Axillary 451 Aortic 5.1% Femoral 6.5% Axillary 3.3% Stroke rate All cause Aorta 3.8% Femoral 2.7% Axillary 0.9% Chronic aortic Aorta 11% Femoral 4% Axillary 0% Acute aortic Aortic 0% Femoral 3% Axillary 3% Budde et al., (2006), Sixty-one patients (41 Death Overall 8.2% Overall stroke rate of 1.6% must Ann Thorac Surg, elective, 20 emergent) Elective surgery likely be due to embolic debris, USA, w15x undergoing surgery for 7.2% suggesting that the type of perfusion acute ascending aortic Emergent surgery did not contribute to this Retrospective cohort syndrome ( and 10% complication intramural haematomas) were cannulated through Neurological Over all 4.9% Shorter hospital stays in the elective the axillary artery for CPB dysfunction Elective surgery group 4.8% Emergent surgery 10% AxqSG, axillary with SG; Ax no SG, axillary with no SG; CVA, cerebrovascular accident; CPB, cardiopulmonary bypass; CI, confidence interval; SG, side graft. icant differences in the incidence of stroke and long-term survival between these two groups. Khaladj and co-workers w3x concluded ascending Ao using the Seldinger technique was a safe, quick and easy to establish. In a review of 122 patients, mortality at 30 days was 15%, which matches statistics reported in other studies. They observed 12% stroke rate and 17% temporary neurological dysfunction. Reece et al. w4x have shown 0% mortality and 21% stroke rate in ascending aortic using the Seldinger technique, while there was a 17% mortality and a 28% stroke rate in the peripheral artery group (femoral and axillary). Furthermore, they suggest that the site of should be tailored to both the specifics of and the patient. If a clot is present in the false lumen, an alternative technique in the ascending aorta should be considered. Reuthebuch and co-authors w5x compared two peripheral s, subclavian artery vs. femoral artery, in 122 patients undergoing surgery for acute type A aortic. They have shown subclavian artery has lower mortality (8.6% vs. 23.3%), lower prolonged postoperative neurological dysfunction (1.75% vs. 17.4%) and lower renal failure (11% vs. 23%). Extension of to the cerebral vessels, ascending aorta, and infrarenal abdominal aorta were higher in femoral group. Sabik et al. w6x specified and studied the effect of axillary artery with a side graft (SG) and without a SG in 391 patients. In their study, the overall mortality was 8%. They concluded that axillary artery with or without SG has similar mortality, but axillary with SG can decrease local complication (e.g. brachial plexus injury) up to 0.5% vs. 2.8% and risk of aortic to 0% vs. 1.4%. Overall, axillary artery can decrease organ malperfusion, retrograde embolization and other complications related to peripheral. From the Cleveland Clinic, Svensson and co-workers w7x reported results of a large cohort of 1336 patients, undergoing complex cardiac surgeries using different techniques like aortic (ns471), axillary with SG (AxqSG) (ns299), axillary with no SG (Ax no SG) (ns167), femoral (ns374) and innominate artery (ns24). Among all these techniques, AxqSG has the lowest mortality (7.0%) and stroke (4.0%) rate. Interestingly, stroke rate is higher (7.8%) in the Ax no SG group. Although, they studied other patients not only those undergoing surgery for type A aortic, they showed axillary artery to be the preferred method of for complex aortic surgery and re-operations. Chiappini et al. w8x reviewed the result of 487 patients treated for acute type A aortic in Italy and The Netherlands. Most of the surgeries (98.2%) were performed using femoral artery for the establishment of the cardiopulmonary bypass (CPB). In their patients, mortality rate was 22% and stroke rate was 18.2%.
K.K. Tiwari et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 797 802 801 Fusco et al. w9x retrospectively studied 86 patients treated for acute aortic. Seventy-nine of them were cannulated through the femoral artery. Fifteen patients died, out of which, only two had documented femoral artery as a related cause of death and one had an aortic related death. They concluded that femoral artery was not the main cause of death and stroke. Unlike others, Conzelmann et al. w10x first performed venous drainage and then opened the ascending aorta followed by direct true lumen during type A aortic surgery. They observed 0% mortality and 21% neurological complications. They proved that technical simplicity and the quick establishment of an additional arterial access was a major advantage when performing surgery of aortic s. Moizumi et al. w11x compared the results of surgery for acute type A aortic using the femoral and axillary arteries in a retrospective study of 106 patients. In univariate and multivariate analysis, absence of axillary artery perfusion is shown to be an independent intraoperative predictor of hospital death. Mortality rate was 7.2% in the axillary group and 30% in the femoral group, proving axillary artery to be an effective method of in improving the results of surgery for acute type A aortic. Inoue et al. w12x conducted a study on direct ascending aortic using the Seldinger technique, guided by epiaortic ultrasound, in 32 patients undergoing surgery for acute type A aortic. They established CPB using femoral artery before switching to ascending aortic. A mortality rate of 3.1% and neurological complication of 6.3% was found. Although, no complication related to the extension of the, false lumen or malperfusion occurred in their series; this technique is time consuming and has the potential risk of retrograde embolization. In 2007, Nouraei et al. w13x retrospectively reviewed the results of 49 patients operated on for acute type A aortic using femoral and subclavian artery over a five-year period. In their series of cases, the subclavian group had a lower mortality rate (10%), while univariate analysis showed femoral as a significant predictor of neurological deficit and mortality. Analysing a large cohort of 869 patients with complex aortic pathologies, Etz et al. w14x have shown that the use of axillary artery for CPB lowers the mortality and stroke rate compared to direct ascending aorta and femoral artery. Budde et al. w15x used axillary to establish CPB in 61 patients undergoing elective and emergent surgery for acute ascending aortic syndrome. There were no significant difference in postoperative temporary neurological dysfunction and mortality in elective and emergent groups: 4.9% vs. 5% and 7.3% vs. 10%, respectively. They claimed that the use of axillary artery in emergent cases was appropriate, efficacious and safe in an elective setting. 7. Clinical bottom line Several techniques have been proposed to establish CPB for surgery of acute type A aortic. In spite of concern over the fragility of vessels and distal embolization during ascending aortic of a dissected aorta, it has promising results with a lower mortality rate, a lower incidence of malperfusion but has a higher stroke rate. A total of seven studies evaluated direct aortic for the establishment of CPB. They demonstrated mortality and stroke rates from 0% to 15% and 3.8% to 21%, respectively. Direct of the true lumen is an emerging method for quick and easy establishment of CPB. Although, femoral artery is the standard option in many centres, it has the highest rate of mortality, stroke rate and other complications including retrograde cerebral embolization, organ malperfusion and perfusion of the false lumen. Five out of 14 papers were found to report in favour of axillary (or subclavian) artery over femoral artery. In a total of 1829 patients evaluated in these studies, 1068 patients demonstrated a significantly lower complication rate with axillary artery than femoral artery. Some of the larger studies showed that femoral artery has higher mortality and stroke rates ranging from 6.5% to 40% and 3% to 17%, respectively. Meanwhile, mortality and stroke rates ranged from 3% to 8.6% and 1.75% to 4%, respectively, in favour of axillary artery. Axillary artery emerges as an elegant method for CPB. It provides continuous unilateral blood flow without interruption. Although it takes more time to construct, axillary artery with a SG is proven to be safe and straightforward, with fewer local and systemic complications, lower mortality and neurological complications. References w1x Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405 409. w2x Kamiya H, Kallenbach K, Halmer D, Özsöz M, Ilg K, Lichtenberg A, Matthias Karck M. Comparison of ascending aorta versus femoral artery for acute aortic type A. Circulation 2009; 120:S282 S286. w3x Khaladj N, Shrestha M, Peterss S, Strueber M, Karck M, Pichlmaier M, Haverich A, Hagl C. Ascending aortic in acute aortic type A: the Hannover experience. Eur J Cardiothorac Surg 2008;32:792 797. w4x Reece TB, Tribble CG, Smith RL, Singh RR, Stiles BM, Peeler BB, Kern JA, Kron IL. Central is safe in acute aortic repair. J Thorac Cardiovasc Surg 2007;133:428 434. w5x Reuthebuch O, Schurr U, Hellermann J, Prêtre R, Künzli A, Lachat M, Turina MI. Advantages of subclavian artery perfusion for repair of acute type A. Eur J Cardiothorac Surg 2004;26:592 598. w6x Sabik JF, Nemeh H, Lytle BW, Blackstone EH, Gillinov AM, Rajeswaran J, Cosgrove DM. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004;77:1315 1320. w7x Svensson LG, Blackstone EH, Rajeswaran J, Sabik JF, Lytle BW, Gonzalez- Stawinski G, Varvitsiotis P, Banbury MK, McCarthy PM, Pettersson GB, Cosgrove DM. Does the arterial site for circulatory arrest influence stroke risk? Ann Thorac Surg 2004;78:1274 1284. w8x Chiappini B, Schepens M, Tan E, Dell Amore A, Morshuis W, Dossche K, Work in Editorial New Ideas Progress Report Protocol Institutional Report ESCVS Article Proposal for Bailout Procedure Negative Results Follow-up Paper State-of-the-art Best Evidence Topic Nomenclature Historical Pages Brief Case Report Communication
802 K.K. Tiwari et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 797 802 Bergonzini M, Camurri N, Reggiani LB, Marinelli G, Di Bartolomeo R. Early and late outcomes of acute type A aortic : analysis of risk factors in 487 consecutive patients. Eur Heart J 2005;26:180 186. w9x Fusco DS, Shaw RK, Tranquilli M, Kopf GS, Elefteriades JA. Femoral is safe for type A repair. Ann Thorac Surg 2004; 78:1285 1289. w10x Conzelmann LO, Kayhan N, Mehlhorn U, Weigang E, Dahm M, Vahl CF. Reevaluation of direct true lumen in surgery for acute type A aortic. Ann Thorac Surg 2009;87:1182 1186. w11x Moizumi Y, Motoyoshi N, Sakuma K, Yoshida S. Axillary artery improves operative results for acute type A aortic. Ann Thorac Surg 2005;80:77 83. w12x Inoue Y, Ueda T, Taguchi S, Kashima I, Koizumi K, Takahashi R, Kiso I. Ascending aorta in acute type A aortic. Eur J Cardiothorac Surg 2007;31:976 981. w13x Nouraei SM, Nouraei SAR, Sadashiva AK, Pillay T. Subclavian improves outcome of surgery for type A aortic. Asian Cardiovasc Thorac Ann 2007;15:118 122. w14x Etz CD, Plestis KA, Kari FA, Silovitz D, Bodian CA, Spielvogel D, Griepp RB. Axillary significantly improves survival and neurologic outcome after atherosclerotic aneurysm repair of the aortic root and ascending aorta. Ann Thorac Surg 2008;86:441 447. w15x Budde JM, Serna DL, Osborne SC, Steele MA, Chen EP. Axillary for proximal aortic surgery is as safe in the emergent setting as in elective cases. Ann Thorac Surg 2006;86:2154 2160. ecomment: Outcome in patients requiring surgery for acute aortic type A: just a matter of site? Authors: Nawid Khaladj, Hannover Medical School Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover, Germany; Sven Peterss, Axel Haverich, Christian Hagl doi:10.1510/icvts.2009.230409a We have read with interest the best evidence topic report by Tiwari and co-workers dealing with the issue of site in patients requiring surgery for acute aortic type A w1x. As stated by the authors, our group has substantial experience in direct of the dissected aorta. Unfortunately, our technique has not been cited correctly w2x. In contrast to other groups, the Hannover technique relies on direct approaching the aorta in a less dissected or non-dissected area, as determined by CT-scan or transesophageal echocardiography. The cannula is supported by double purse-string sutures. We are aware that the routine use of this technique in elective patients with thin-walled aortic aneurysms is a prerequisite for this specific approach, including troubleshooting strategies in case of aortic rupture or malperfusion. There is no question that neurological complications are a multi-factorial process in this high-risk patient cohort. Nevertheless, temporary neurological complications as well as frank strokes can be dedicated by the underlying pathology but also cerebral protection techniques w3x. However, when techniques are applied to establish antegrade flow, they are frequently combined with selective antegrade cerebral perfusion which is often associated with better neurological outcome w4x. In most of the published studies, it remains unclear whether strokes were counted if the patients died during hospital stay. This is an important information, as it has been shown that mortality rates are higher in patients suffering from peri-operative strokes. Clear guidelines for reporting mortality and morbidity after aortic surgery are therefore mandatory, according to the current ones published for valve surgery w5x. References w1x Tiwari KK, Murzi M, Bevilacqua S, Glauber M. Which (ascending aortic or peripheral arterial ) is better for acute type A aortic surgery? Interact CardioVasc Thorac Surg 2010;10:797 802. w2x Khaladj N, Shrestha M, Peterss S, Strueber M, Karck M, Pichlmaier M, Haverich A, Hagl C. Ascending aortic in acute aortic type A: the Hannover experience. Eur J Cardiothorac Surg 2008;34:792 796; discussion 796. w3x Hagl C, Ergin MA, Galla JD, Lansman SL, McCullough JN, Spielvogel D, Sfeir P, Bodian CA, Griepp RB. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg 2001;121:1107 1121. w4x Khaladj N, Shrestha M, Meck S, Peterss S, Kamiya H, Kallenbach K, Winterhalter M, Hoy L, Haverich A, Hagl C. Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. J Thorac Cardiovasc Surg 2008;135:908 914. w5x Akins CW, Miller DC, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL, Takkenberg JJ, David TE, Butchart EG, Adams DH, Shahian DM, Hagl S, Mayer JE, Lytle BW. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Eur J Cardiothorac Surg 2008;33:523 528.