Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection

Praveen Nayak; Archit Patel; Mausam Shah; Chirag Doshi

doi:10.4103/heartindia.heartindia_7_23

ORIGINAL ARTICLE

Year : 2023 | Volume : 11 | Issue : 1 | Page : 8-12

Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection

Praveen Nayak, Archit Patel, Mausam Shah, Chirag Doshi
Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India

Date of Submission	25-Jan-2023
Date of Decision	01-Mar-2023
Date of Acceptance	03-Mar-2023
Date of Web Publication	12-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
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/heartindia.heartindia_7_23

Abstract

Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula.
Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality.
Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen.
Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.

Keywords: Antegrade cerebral perfusion, ascending aortic dissection, cardiopulmonary bypass, deep hypothermic cardiac arrest

How to cite this article:
Nayak P, Patel A, Shah M, Doshi C. Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection. Heart India 2023;11:8-12

How to cite this URL:
Nayak P, Patel A, Shah M, Doshi C. Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection. Heart India [serial online] 2023 [cited 2023 May 28];11:8-12. Available from: https://www.heartindia.net/text.asp?2023/11/1/8/374105

Introduction

Aortic arch surgeries were first performed in 1950 by Dr. Michael De Bakey, E. Stanley Crawford, and Denton A. Cooley.^[1],[2] It was very well understood that the key to success in transverse aortic surgery lies in protecting the function of the brain. One such landmark surgery was performed in the year 1964 by Dr. Borst et al. using deep hypothermic cardiac arrest in a patient with an aortopulmonary fistula inflicted due to bullet injury in WW II.^[3] Next milestone in the field of modern aortic surgery happened in the year 1986 when Dr. Jean Bachet and Dr. Daniel Guilmet in Europe and Dr. Teuhisa Kazui and colleagues in Japan introduced antegrade selective cerebral perfusion in combination with systemic hypothermia which significantly reduced the incidence of neurological complications.^[4],[5]

Aortic dissection, especially acute type A, is one of the most lethal conditions in cardiac surgery; even when presented early to the hospital, worldwide mortality is about 20%–30%. This condition can be fatal if the dissection involves coronary ostium and also when the dissection flap extends into one of the major neck vessels. If dissection involves an innominate artery (IA), prompt restoration cerebral perfusion is necessary to avoid neurological complications and if dissection extends further various other vital organ malperfusion can happen and the perioperative outcome depends on it.^[6] The surgical repair in such a condition is quite challenging and needs the best possible cannulation strategy for neurological protection. Various cannulation strategies were developed in the field of aortic surgery, and recently, it has been stated that aortic arch surgeries with double arterial cannulation and moderate hypothermia have the best outcome concerning neuroprotection and malperfusion of various organs.

Double arterial cannulation technique such as the right axillary artery has their complications such as seroma, infection, stump blowout, and brachial plexus injury.^[7],[8] IA cannulation by Seldinger's technique or by direct open technique has its disadvantage in acute dissection where the tissues are fragile and chances of iatrogenic IA injury are high. Hence, we studied this technique where dissected flap and true lumen of the IA are identified, and ostial cannulation is done under vision.

Patients and Methods

The retrospective analysis was done at the U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, which is the tertiary-level referral cardiac center in Western India. Patients who underwent surgery between November 01, 2020 and November 30, 2022 matching the inclusion criteria were selected, and their clinical history and operative technique were noted, and data were collected. Demographic details and associated comorbidities are enlisted in [Table 1]. The primary surgery and associated surgery performed are shown in [Table 2]. The primary end point of the study was the incidence of stroke, seizures, psychosis, and neurological deficit (marked as yes or no) and secondary outcomes were the incidence of end-organ malperfusion, duration of intensive care unit (ICU) stay, hospital stay and surgical time, and 30-day mortality. Data were acquired from the operative record and follow-up data during the patient's visit to the hospital accessed by HIMS Software.

Table 1: Demographic data of the study patients

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Table 2: Surgical procedures performed

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Operative technique

Under general anesthesia, patients were laid supine, the central line placed through right internal jugular vein, right both radial arterial pressure monitored. All patients underwent median sternotomy with incision extending 2–3 cm above the sternal notch; innominate vein was dissected and looped and pulled down to access the arch vessels. IA was dissected and looped at the base, and similarly, left common carotid and subclavian artery were dissected and looped. Y-shaped connector was used in the arterial line of the cardiopulmonary bypass (CPB) machine one end of which was directed for femoral arterial cannulation, and the other limb was connected to balloon-tip retrograde cardioplegia cannula and clamped and kept free. The cardioplegia line was connected to a multiport, retrograde was given through coronary sinus, and the other limb of multiport was kept free to give antegrade ostial cardioplegia when required.

The anatomy was assessed after pericardiotomy and CPB was instituted using the side uninvolved femoral artery, and bilateral radial arterial pressure was monitored; this antegrade cerebral perfusion (ACP) strategy was abandoned if there is a significant discrepancy in bilateral radial artery mean pressure.

After confirmation of radial pressure, ascending aorta was clamped proximal to IA, and retrograde cardioplegia was given through the coronary sinus, and heart was arrested and systemic cooling started, and during the cooling period, proximal reconstruction was done; details of the procedure are given in [Table 1]. When the temperature reached 28°–26°, circulatory arrest was achieved, and cross-clamp on the ascending aorta was released, and ascending aorta was dissected to find the IA ostia, and true lumen was identified, and under vision cannulation using balloon-tip retrograde cannula, the base of the innominate gently snugged, and the side port was connected to a continuous pressure monitor. About 25–30 ml/min cold blood was given through the retrograde cannula to maintain the pressure around 40–50 mmHg. Further dissection of the aortic arch to find a dissection flap, and distal anastomosis was started and gradual rewarming was started, just at the end of anastomosis gradual flow through the femoral cannula started, and deairing was done, the cardioplegia cannula pulled out and anastomosis competed. CPB resumed with femoral cannula while maintaining adequate right radial pressure. Hemostasis was checked and the patient weaned from CPB.

Results

The age of the patients ranged from 20 to 74 years with a mean age of 40 years, predominately being males. Clinical history was noted including symptom onset, duration, NYHA class, comorbidities: diabetes, hypertension, Marfan's syndrome, smoking, stroke, transient ischemic attack, seizures, and history of previous surgery as shown in [Table 1]. The majority of patients underwent supracoronary ascending aortic replacement. Primarily among this subset, three patients underwent concomitant surgeries (mitral valve repair, coronary artery bypass grafting, and right femoral-popliteal bypass). Three patients underwent modified Bentall's procedure with hemiarch replacement, and one patient underwent David's procedure with hemiarch replacement [Table 2]. One patient had an injury to the base of IA during which selective cannulation was done and was reimplanted on ascending aorta graft using 6 mm Dacron graft. The mean operative time was 3 h and 47 min containing the mean cross-clamp time was 51.44 min and mean CPB time was 76.11 min. Patients had mean circulatory arrest period of 14.22 min, and temperature during circulatory arrest ranged between 28° and 30°.

All the patients were analyzed for primary outcome: none of the patients had a stroke or seizures in the study patients. One patient had mild psychosis during the ICU stay and was managed medically. The mean ICU stay was 4.33 days [Table 3]. One patient had a prolonged ICU stay (10 days) as he had reexploration for bleeding, multiple transfusion, sepsis, and acute kidney injury. Two patients had raised serum creatinine requiring intravenous diuretics; however, none of the patients had to undergo hemodialysis. Hospital stay ranged between 4 and 14 days (mean 7.77 days), and all the patients attended a second follow-up after 30 days in outpatient department as per HIMS data.

Table 3: Perioperative outcome

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Statistical analysis

The analysis of categorical variables was presented as number percentage. And continuous variables described as the mean.

Discussion

Type A ascending aortic dissection (AAD) has a varied causes and presentation; most of them present with varying degree of spontaneous chest pain or upper back pain in an emergency. Nearly 10%–50% present without pain and nearly 18%–30% present with neurological complications. Prompt detection and surgical treatment are the key to success, early mortality in such patients is nearly 50%.^[9] Type A aortic dissection involving supra-aortic vessels has a reported incidence with a wide range of 5%–43%, IA being the most common.^[10],[11]

The main principle of surgical repair is to provide bloodless, motionless field with uninterrupted cerebral blood flow while repairing the type A aortic dissection with dissection flap extending into an IA or left CCA. One common technique of ACP is right axillary cannulation, but it has its demerits.^[12],[13] To mitigate this drawback, direct cannulation of IA either using a side graft or direct Seldinger's technique has been advocated, but this technique can be safely used only in patients undergoing elective aortic surgery.^[14] Angleitner et al. studied unilateral cerebral perfusion versus bilateral cerebral perfusion, and the results were slightly in favor of bilateral cerebral perfusion,^[15] but their total CPB time and circulatory arrest time were much higher when compared to our cases. In our study, we did direct under vision ostial cannulation of IA as a sole technique of unilateral ACP after achieving circulatory arrest under moderate hypothermia in patients with AAD, and there was no incidence of stroke or neurological insult.

Various studies have reported alternate techniques of ACP and their associated complications. Huang et al. used a side graft to innominate the artery in 46 patients and reported temporary neurological complications in 10.9% of patients.^[16] Similarly, Di Eusanio et al. reported transient neurological dysfunction in 1.8% of patients.^[17] Garg et al. cannulated IA directly with 14F pediatric venous cannula with 2% mortality and 2% stroke.^[18] Similar technique was used by Jassar et al.,^[19] but with 9F pediatric venous cannula in a larger number of patients with a stroke rate of 1%. We used the simple technique of inserting balloon-tip retrograde cardioplegia cannula after finding the true lumen and the base of IA was gently snugged, none of the patients in our case series had a stroke, neurological dysfunction, or mortality.

Chan et al.^[20] reported the usage of balloon-tip catheter in with cerebral regional oxygen saturation (rSO₂) monitoring in a patient with aortic arch surgery which concludes that if right radial pressure or rSO₂ is monitored properly, neurological complications can be avoided. We used same technique bin all the patients with acute aortic dissection and found that none of the patients had a stroke; one patient had mild psychosis which could be managed medically.

Liu et al. observed that bilateral ACP was better in terms of shorter CPB time and low incidence perioperative neurological dysfunction;^[21] in our study, we did not find any neurological dysfunction in postoperative period and also CPB time was much shorter. It can be stated that, if the circulatory arrest time is <30 min, this technique can be safely used, although limited by a small sample size, our study has promising results with minimal complications validating its usage as an alternate technique.

Conclusion

This technique is simple, cost-effective, and less time-consuming and can be used in emergent or urgent AAD surgery with flap extending into IA and mitigates the need for axillary artery dissection and its complication. This also avoids open direct cannulation of an IA in the setting of AAD where tissues are thin and fragile. Since this is a case series of nine patients, we need further multicentric prospective studies with a larger sample size to validate the result of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical approval

Institutional Ethics Committee approval was obtained for this study.

Authors' contributions

Dr. Pravin Nayak: Conceptualisation, Design, Acquisition, Draft; Dr. Archit Patel: Draft, Design, Interpretation; Dr Mausam Shah: Literature review, data analysis; Dr. Chirag Doshi: Design, draft, Proof check.

References

1.	Cooley DA, De Bakey ME. Surgical considerations of intrathoracic aneurysms of the aorta and great vessels. Ann Surg 1952;135:660-80.
2.	De Bakey ME, Cooley DA. Successful resection of aneurysm of thoracic aorta and replacement by graft. J Am Med Assoc 1953;152:673-6.
3.	Borst HG, Schaudig A, Rudolph W. Arteriovenous fistula of the aortic arch: Repair during deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg 1964;48:443-7.
4.	Guilmet D, Roux PM, Bachet J, Goudot B, Tawil N, Diaz F. A new technic of cerebral protection. Surgery of the aortic arch. Presse Med 1986;15:1096-8.
5.	Kazui T. Update in surgical management of aneurysms of the thoracic aorta. Rinsho Kyobu Geka 1986;6:7-15.
6.	Girdauskas E, Kuntze T, Borger MA, Falk V, Mohr FW. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg 2009;138:1363-9.
7.	Strauch JT, Spielvogel D, Lauten A, Lansman SL, McMurtry K, Bodian CA, et al. Axillary artery cannulation: Routine use in ascending aorta and aortic arch replacement. Ann Thorac Surg 2004;78:103-8.
8.	Chu MW, Losenno KL, Gelinas JJ, Garg V, Dickson J, Harrington A, et al. Innominate and axillary cannulation in aortic arch surgery provide similar neuroprotection. Can J Cardiol 2016;32:117-23.
9.	Pastuszak Ż, Stępień A, Kordowska J, Rolewska A, Galbarczyk D. Brain strokes related to aortic aneurysma – The analysis of three cases. Open Med (Wars) 2017;12:58-61.
10.	Luehr M, Etz CD, Nozdrzykowski M, Lehmkuhl L, Misfeld M, Bakhtiary F, et al. Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissection. Eur J Cardiothorac Surg 2016;49:652-8.
11.	Yamauchi T, Ueda H, Kubota S, Hasegawa K. Residual dissected brachiocephalic artery aneurysm after repair of acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2017;24:310-2.
12.	Wong DR, Coselli JS, Palmero L, Bozinovski J, Carter SA, Murariu D, et al. Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections. Ann Thorac Surg 2010;90:731-7.
13.	Schachner T, Nagiller J, Zimmer A, Laufer G, Bonatti J. Technical problems and complications of axillary artery cannulation. Eur J Cardiothorac Surg 2005;27:634-7.
14.	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.
15.	Angleitner P, Stelzmueller ME, Mahr S, Kaider A, Laufer G, Ehrlich M. Bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection. J Thorac Cardiovasc Surg 2020;159:2159-67.e2.
16.	Huang FJ, Wu Q, Ren CW, Lai YQ, Yang S, Rui QJ, et al. Cannulation of the innominate artery with a side graft in arch surgery. Ann Thorac Surg 2010;89:800-3.
17.	Di Eusanio M, Ciano M, Labriola G, Lionetti G, Di Eusanio G. Cannulation of the innominate artery during surgery of the thoracic aorta: Our experience in 55 patients. Eur J Cardiothorac Surg 2007;32:270-3.
18.	Garg V, Tsirigotis DN, Dickson J, Dalamagas C, Latter DA, Verma S, et al. Direct innominate artery cannulation for selective antegrade cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery. J Thorac Cardiovasc Surg 2014;148:2920-4.
19.	Jassar AS, Vallabhajosyula P, Bavaria JE, Gutsche J, Desai ND, Williams ML, et al. Direct innominate artery cannulation: An alternate technique for antegrade cerebral perfusion during aortic hemiarch reconstruction. J Thorac Cardiovasc Surg 2016;151:1073-8.
20.	Chan SK, Underwood MJ, Ho AM, So JM, Ho AK, Wan IY, et al. Cannula malposition during antegrade cerebral perfusion for aortic surgery: Role of cerebral oximetry. Can J Anaesth 2014;61:736-40.
21.	Liu Z, Wang C, Zhang X et al. Effect of different types of cerebral perfusion for acute type A aortic arch dissection undergoing aortic arch procedure, unilateral versus bilateral. BMC Surg 2020;20:286.