Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach

Brad F. Rosinski; Jay J. Idrees; Eric E. Roselli; Emídio Germano; Selena R. Pasadyn; Ashley M. Lowry; Eugene H. Blackstone; Douglas R. Johnston; Edward G. Soltesz; José L. Navia; Milind Y. Desai; Stephanie L. Mick; Faisal G. Bakaeen; Lars G. Svensson

doi:10.1016/j.jtcvs.2018.11.137

Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach

Brad F. Rosinski, Jay J. Idrees, Eric E. Roselli, Emídio Germano, Selena R. Pasadyn, Ashley M. Lowry, Eugene H. Blackstone, Douglas R. Johnston, Edward G. Soltesz, José L. Navia, Milind Y. Desai, Stephanie L. Mick, Faisal G. Bakaeen, Lars G. Svensson^*

^*Corresponding author for this work

Surgery, Cardiac Surgery Division

Research output: Contribution to journal › Article › peer-review

48 Scopus citations

Abstract

Objectives: Consensus regarding initial cannulation site for acute type A dissection repair is lacking. Objectives were to review our experience with systematic initial axillary artery cannulation, characterize patients on the basis of cannulation site, and assess outcomes. Methods: From January 2000 to January 2017, 775 patients underwent emergency acute type A dissection repair. Initial axillary cannulation was performed in 617 (80%), femoral in 93 (12%), and central in 65 (8.4%). In-hospital mortality and stroke risk factors were identified using logistic regression. Results: Reasons for selecting initial central or femoral instead of axillary cannulation included unsuitable axillary anatomy (n = 67; 42%), surgeon preference (n = 38; 24%), hemodynamic instability (n = 34; 22%), and preexisting cannulation (n = 19; 12%). Cannulation site was shifted or added intraoperatively in 82 (11%), with initial cannulation site being axillary (n = 23 of 617; 3.7%), central (6 of 65; 9.2%), or femoral (n = 53 of 93; 57%), for surgeon preference (n = 60; 73%), high flow resistance (n = 13; 16%), increased aortic false lumen flow (n = 6; 7.3%), and other (n = 3; 3.7%). In-hospital mortality was 8.6% (n = 67; lowest for axillary, 7.3% [P =.02]) and stroke 8.3% (n = 64). Hemodynamic instability (odds ratio [OR], 7.6; 95% confidence interval [CI], 4.2-14), limb ischemia (OR, 3.7; 95% CI, 1.5-9.3), stroke (OR, 5.5; 95% CI, 2.2-14), and aortic regurgitation (OR, 2.2; 95% CI, 1.2-4.2) at presentation were risk factors for mortality and central cannulation site (OR, 2.3; 95% CI, 1.05-5.1) and aortic stenosis (OR, 2.4; 95% CI, 1.2-4.6) for stroke. Conclusions: Systematic initial axillary cannulation for acute type A dissection repair is safe and effective and can be tailored to patients' specific needs. With this strategy, comparable outcomes are observed among cannulation sites and are largely determined according to patient presentation rather than cannulation site.

Original language	English (US)
Pages (from-to)	647-659.e5
Journal	Journal of Thoracic and Cardiovascular Surgery
Volume	158
Issue number	3
DOIs	https://doi.org/10.1016/j.jtcvs.2018.11.137
State	Published - Sep 2019

Funding

This study was funded in part by the Delos M. Cosgrove, MD, Chair for Heart Disease Research, the Dana Hamel Family Fund, the High Risk Cardiovascular Surgery Research Fund, the Gus P. Karos Registry Fund, the David Whitmire Hearst, Jr, Foundation, the Drs Sidney and Becca Fleischer Heart and Vascular Education Chair, the Haslam Family Endowed Chair in Cardiovascular Medicine, and the Sheikh Hamdan bin Rashid Al Maktoum Distinguished Chair in Thoracic and Cardiovascular Surgery. The authors thank Patrick R. Vargo, MD, and Brian Kohlbacher for creating the video.

Keywords

DeBakey type I dissection
cardiopulmonary bypass cannulation

ASJC Scopus subject areas

Surgery
Pulmonary and Respiratory Medicine
Cardiology and Cardiovascular Medicine

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10.1016/j.jtcvs.2018.11.137

Cite this

Rosinski, B. F., Idrees, J. J., Roselli, E. E., Germano, E., Pasadyn, S. R., Lowry, A. M., Blackstone, E. H., Johnston, D. R., Soltesz, E. G., Navia, J. L., Desai, M. Y., Mick, S. L., Bakaeen, F. G., & Svensson, L. G. (2019). Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach. Journal of Thoracic and Cardiovascular Surgery, 158(3), 647-659.e5. https://doi.org/10.1016/j.jtcvs.2018.11.137

@article{6f84eb3efa1c4f7fa9e0a1cfcd6f6aea,

title = "Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach",

abstract = "Objectives: Consensus regarding initial cannulation site for acute type A dissection repair is lacking. Objectives were to review our experience with systematic initial axillary artery cannulation, characterize patients on the basis of cannulation site, and assess outcomes. Methods: From January 2000 to January 2017, 775 patients underwent emergency acute type A dissection repair. Initial axillary cannulation was performed in 617 (80%), femoral in 93 (12%), and central in 65 (8.4%). In-hospital mortality and stroke risk factors were identified using logistic regression. Results: Reasons for selecting initial central or femoral instead of axillary cannulation included unsuitable axillary anatomy (n = 67; 42%), surgeon preference (n = 38; 24%), hemodynamic instability (n = 34; 22%), and preexisting cannulation (n = 19; 12%). Cannulation site was shifted or added intraoperatively in 82 (11%), with initial cannulation site being axillary (n = 23 of 617; 3.7%), central (6 of 65; 9.2%), or femoral (n = 53 of 93; 57%), for surgeon preference (n = 60; 73%), high flow resistance (n = 13; 16%), increased aortic false lumen flow (n = 6; 7.3%), and other (n = 3; 3.7%). In-hospital mortality was 8.6% (n = 67; lowest for axillary, 7.3% [P =.02]) and stroke 8.3% (n = 64). Hemodynamic instability (odds ratio [OR], 7.6; 95% confidence interval [CI], 4.2-14), limb ischemia (OR, 3.7; 95% CI, 1.5-9.3), stroke (OR, 5.5; 95% CI, 2.2-14), and aortic regurgitation (OR, 2.2; 95% CI, 1.2-4.2) at presentation were risk factors for mortality and central cannulation site (OR, 2.3; 95% CI, 1.05-5.1) and aortic stenosis (OR, 2.4; 95% CI, 1.2-4.6) for stroke. Conclusions: Systematic initial axillary cannulation for acute type A dissection repair is safe and effective and can be tailored to patients' specific needs. With this strategy, comparable outcomes are observed among cannulation sites and are largely determined according to patient presentation rather than cannulation site.",

keywords = "DeBakey type I dissection, cardiopulmonary bypass cannulation",

author = "Rosinski, {Brad F.} and Idrees, {Jay J.} and Roselli, {Eric E.} and Em{\'i}dio Germano and Pasadyn, {Selena R.} and Lowry, {Ashley M.} and Blackstone, {Eugene H.} and Johnston, {Douglas R.} and Soltesz, {Edward G.} and Navia, {Jos{\'e} L.} and Desai, {Milind Y.} and Mick, {Stephanie L.} and Bakaeen, {Faisal G.} and Svensson, {Lars G.}",

note = "Publisher Copyright: {\textcopyright} 2019",

year = "2019",

month = sep,

doi = "10.1016/j.jtcvs.2018.11.137",

language = "English (US)",

volume = "158",

pages = "647--659.e5",

journal = "Journal of Thoracic and Cardiovascular Surgery",

issn = "0022-5223",

publisher = "Mosby Inc.",

number = "3",

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Rosinski, BF, Idrees, JJ, Roselli, EE, Germano, E, Pasadyn, SR, Lowry, AM, Blackstone, EH, Johnston, DR, Soltesz, EG, Navia, JL, Desai, MY, Mick, SL, Bakaeen, FG & Svensson, LG 2019, 'Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach', Journal of Thoracic and Cardiovascular Surgery, vol. 158, no. 3, pp. 647-659.e5. https://doi.org/10.1016/j.jtcvs.2018.11.137

TY - JOUR

T1 - Cannulation strategies in acute type A dissection repair

T2 - A systematic axillary artery approach

AU - Rosinski, Brad F.

AU - Idrees, Jay J.

AU - Roselli, Eric E.

AU - Germano, Emídio

AU - Pasadyn, Selena R.

AU - Lowry, Ashley M.

AU - Blackstone, Eugene H.

AU - Johnston, Douglas R.

AU - Soltesz, Edward G.

AU - Navia, José L.

AU - Desai, Milind Y.

AU - Mick, Stephanie L.

AU - Bakaeen, Faisal G.

AU - Svensson, Lars G.

PY - 2019/9

Y1 - 2019/9

N2 - Objectives: Consensus regarding initial cannulation site for acute type A dissection repair is lacking. Objectives were to review our experience with systematic initial axillary artery cannulation, characterize patients on the basis of cannulation site, and assess outcomes. Methods: From January 2000 to January 2017, 775 patients underwent emergency acute type A dissection repair. Initial axillary cannulation was performed in 617 (80%), femoral in 93 (12%), and central in 65 (8.4%). In-hospital mortality and stroke risk factors were identified using logistic regression. Results: Reasons for selecting initial central or femoral instead of axillary cannulation included unsuitable axillary anatomy (n = 67; 42%), surgeon preference (n = 38; 24%), hemodynamic instability (n = 34; 22%), and preexisting cannulation (n = 19; 12%). Cannulation site was shifted or added intraoperatively in 82 (11%), with initial cannulation site being axillary (n = 23 of 617; 3.7%), central (6 of 65; 9.2%), or femoral (n = 53 of 93; 57%), for surgeon preference (n = 60; 73%), high flow resistance (n = 13; 16%), increased aortic false lumen flow (n = 6; 7.3%), and other (n = 3; 3.7%). In-hospital mortality was 8.6% (n = 67; lowest for axillary, 7.3% [P =.02]) and stroke 8.3% (n = 64). Hemodynamic instability (odds ratio [OR], 7.6; 95% confidence interval [CI], 4.2-14), limb ischemia (OR, 3.7; 95% CI, 1.5-9.3), stroke (OR, 5.5; 95% CI, 2.2-14), and aortic regurgitation (OR, 2.2; 95% CI, 1.2-4.2) at presentation were risk factors for mortality and central cannulation site (OR, 2.3; 95% CI, 1.05-5.1) and aortic stenosis (OR, 2.4; 95% CI, 1.2-4.6) for stroke. Conclusions: Systematic initial axillary cannulation for acute type A dissection repair is safe and effective and can be tailored to patients' specific needs. With this strategy, comparable outcomes are observed among cannulation sites and are largely determined according to patient presentation rather than cannulation site.

AB - Objectives: Consensus regarding initial cannulation site for acute type A dissection repair is lacking. Objectives were to review our experience with systematic initial axillary artery cannulation, characterize patients on the basis of cannulation site, and assess outcomes. Methods: From January 2000 to January 2017, 775 patients underwent emergency acute type A dissection repair. Initial axillary cannulation was performed in 617 (80%), femoral in 93 (12%), and central in 65 (8.4%). In-hospital mortality and stroke risk factors were identified using logistic regression. Results: Reasons for selecting initial central or femoral instead of axillary cannulation included unsuitable axillary anatomy (n = 67; 42%), surgeon preference (n = 38; 24%), hemodynamic instability (n = 34; 22%), and preexisting cannulation (n = 19; 12%). Cannulation site was shifted or added intraoperatively in 82 (11%), with initial cannulation site being axillary (n = 23 of 617; 3.7%), central (6 of 65; 9.2%), or femoral (n = 53 of 93; 57%), for surgeon preference (n = 60; 73%), high flow resistance (n = 13; 16%), increased aortic false lumen flow (n = 6; 7.3%), and other (n = 3; 3.7%). In-hospital mortality was 8.6% (n = 67; lowest for axillary, 7.3% [P =.02]) and stroke 8.3% (n = 64). Hemodynamic instability (odds ratio [OR], 7.6; 95% confidence interval [CI], 4.2-14), limb ischemia (OR, 3.7; 95% CI, 1.5-9.3), stroke (OR, 5.5; 95% CI, 2.2-14), and aortic regurgitation (OR, 2.2; 95% CI, 1.2-4.2) at presentation were risk factors for mortality and central cannulation site (OR, 2.3; 95% CI, 1.05-5.1) and aortic stenosis (OR, 2.4; 95% CI, 1.2-4.6) for stroke. Conclusions: Systematic initial axillary cannulation for acute type A dissection repair is safe and effective and can be tailored to patients' specific needs. With this strategy, comparable outcomes are observed among cannulation sites and are largely determined according to patient presentation rather than cannulation site.

KW - DeBakey type I dissection

KW - cardiopulmonary bypass cannulation

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DO - 10.1016/j.jtcvs.2018.11.137

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SP - 647-659.e5

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JF - Journal of Thoracic and Cardiovascular Surgery

IS - 3

ER -

Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach

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