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 http://aan.sagepub.com/ Asian Cardiovascular and Thoracic Annals

 http://aan.sagepub.com/content/22/3/284The online version of this article can be found at:

 DOI: 10.1177/0218492313481785

 2014 22: 284 originally published online 8 October 2013Asian Cardiovascular and Thoracic Annals 

Nobuyuki Yamamoto, Masaki Nie, Yousuke Hari, Yuki Tanaka, Kuniyoshi Ohara and Kagami MiyajiA selection of cases of direct cannulation in surgery for type A dissection

 

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Original Article

A selection of cases of direct cannulationin surgery for type A dissection

Nobuyuki Yamamoto1, Masaki Nie1, Yousuke Hari2,

Yuki Tanaka1, Kuniyoshi Ohara1 and Kagami Miyaji2

Abstract

Background: We use antegrade cannulation, circulatory arrest, and selective antegrade cerebral perfusion in patientswith acute aortic dissection. While blood is generally supplied via the ascending aorta, this route can be difficult,depending on the features of dissection and the form of the true lumen. In such cases, we incise the ascending aortaand insert the cannula directly into the true lumen of the ascending aorta to secure the blood supply.Methods: Between April 2005 and April 2012, direct true lumen cannulation of the ascending aorta was performed in12 patients; 5 had total arch replacement, and 7 had ascending aorta and hemiarch replacement.Results:  Total arch replacement involved circulatory arrest for 62 16 min, aortic crossclamping for 174 13 min,cardiopulmonary bypass for 211 11 min, and a minimal rectal temperature of 28.4C 1.8C. Ascending aorta andhemiarch replacement involved arrest of the circulation for 40 9 min, aortic crossclamping for 111 29 min, cardio-pulmonary bypass for 131 34 min, and a minimal rectal temperature of 27.8C 0.9C. One patient died from cerebralinfarction during hospitalization.Conclusion: In these cases, direct true lumen cannulation of the ascending aorta was effective.

Keywords

Aneurysm, dissecting, aortic aneurysm, blood vessel prosthesis implantation, cardiopulmonary bypass

Introduction

When surgery for acute type A aortic dissection is per-

formed in our hospital, we adopt antegrade cannula-

tion, circulatory arrest, and selective antegrade cerebral

perfusion, with the ascending aorta selected for blood

supply. However, establishing the blood supply route

can be difficult, for example, when preoperative com-

puted tomography or intraoperative ultrasonography

reveal full-circumference dissection of the tunica

intima of the ascending aorta, in patients with a nar-

rowed true lumen, or when the true lumen is located on

the posterior aspect of the aorta. In such cases, we

incise the ascending aorta and insert a cannula directly

into the true lumen to secure a blood supply route.

Patients and methods

Between April 2005 and April 2012, surgery for acute

type A aortic dissection was carried out in 53 patients; 4

who needed aortic root replacement were excluded

from the study because direct true lumen cannulation

was not performed. Of these 53 patients, 12 had direct

true lumen cannulation of the ascending aorta to

achieve an adequate blood supply; there were 4 men

and 8 women, with a mean age of 66 9 years. Their

characteristics are summarized in Table 1. Other blood

supply routes were via the ascending aorta in 15 cases,

the cardiac apex in 20, and the femoral artery in 6.

Preoperative contrast-enhanced computed tomog-

raphy and intraoperative epiaortic ultrasonography

were employed to judge whether cannulation via the

ascending aorta was possible. If ascending aortic can-

nulation was judged to be difficult (full-circumference

Asian Cardiovascular & Thoracic Annals

2014, Vol. 22(3) 284–287

 The Author(s) 2013

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DOI: 10.1177/0218492313481785

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1Department of Cardiovascular Surgery, Ebina General Hospital,

Kanagawa, Japan2Department of Cardiovascular Surgery, Kitasato University School of 

Medicine, Kanagawa, Japan

Corresponding author:

Nobuyuki Yamamoto, MD, Department of Cardiovascular Surgery, Ebina

General Hospital, Kawaraguchi 1320, Ebina, Kanagawa 243-0433, Japan.

Email: nobun63@yahoo.co.jp

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dissection of the tunica intima, narrowed true lumen, or

true lumen located on the posterior aspect of the aorta),

direct true lumen cannulation of the ascending aorta

was selected (Figure 1).

We used the technique of direct true lumen cannu-

lation described by Jakob and colleagues1 and

Conzelmann and colleagues.2,3

A blood outlet tubewas inserted into the right atrium, a vent was inserted

into the pulmonary artery, the ascending aorta was

taped and a tourniquet was applied. With the patient

maintained in a head-low position, blood pressure was

reduced to 30–40 mm Hg, and the ascending aorta was

incised. After identifying the true lumen, a cannula for

blood supply was inserted directly into it, a tourniquet

was applied to the ascending aorta and fastened, andcardiopulmonary bypass (CPB) was instituted. When

ventricular fibrillation occurred during cooling, cardio-

plegia was employed to induce cardiac arrest. When the

rectal temperature reached 30C, the circulation

arrested. Cannulas were inserted into the left subclavian

artery, the left common carotid artery, and the right

brachiocephalic artery, and selective antegrade cerebral

perfusion was initiated. The point of entry was identi-

fied, and the operative procedure was determined based

on this point.

Quantitative variables are expressed as

mean standard deviation. Comparisons between

groups were made using Student’s   t   test. Values of 

 p< 0.05 were considered statistically significant.

Results

The operative procedure was total arch replacement in

5 cases and ascending aortic replacement with hemiarch

replacement in 7. In all 12 cases, the operations were

completed uneventfully. Table 2 shows the operative

details relating to the 3 techniques of antegrade cannu-

lation. The cases of femoral cannulation were excluded

from the analysis because this method provides retro-

grade perfusion. In the 12 patients who had direct true

Figure 1.   Preoperative contrast-enhanced computed tomography showing (A) the distal ascending aorta and (B) the ascending

aorta at the level of the bifurcation of the pulmonary trunk. T: true lumen.

Table 1.   Preoperative characteristics of 12 patients who had

direct true lumen cannulation for cerebral perfusion in type A

aortic dissection surgery.

Variable No. of patients

Age (years) 66 9

Female 8

Male 4

Stanford type A 12 (100%)Resuscitation 0

Cardiac tamponade 1 (80%)

Cerebral malperfusion 1 (8%)

Hypertension 10 (83%)

Diabetes mellitus 0

Hyperlipidemia 2 (16%)

Hyperuricemia 3 (25%)

Renal dysfunction* 3 (25%)

COPD 1 (8%)

Pneumonia 1 (8%)

*Creatine >1.5mgdL1

. COPD: chronic obstructive pulmonary disease.

Yamamoto et al.   285

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lumen cannulation, the time until awakening (response

to instruction) after surgery was 8 5h. In 2 of these

patients who had developed pneumonia or chronic

obstructive pulmonary disease before surgery, weaning

from the ventilator took at least 7 days; in the other 10,

the ventilator was used for 37 27 h. One patient died

from cerebral infarction during hospitalization, theother 11 are alive and presently receiving outpatient

care (Table 3).

Discussion

When surgery for acute type A aortic dissection is per-

formed, the cerebral blood supply route is controver-

sial. In view of sporadic reports on repeat dissection or

embolism caused by retrograde cannulation or enceph-

alopathy caused by malperfusion, we make it a rule to

select antegrade cannulation which allows a reliable

blood supply through the true lumen at a sufficient

volume. The cardiac apex or ascending aorta serve as

the blood supply route.3–7 Initially, we selected the car-

diac apex for the blood supply route but experienced

difficulty repairing the blood inlet site. For this reason,

we now adopt the ascending aorta whenever possible.

However, establishing a blood supply route via the

ascending aorta can be difficult, such as in full-circum-

ference dissection of the tunica intima, a narrowed true

lumen, or true lumen located on the posterior aspect of 

the aorta. In such cases, we explore a site that would

allow blood to be supplied via the ascending aorta, and

insert a cannula into that site. In one of such cases, we

found that upon arrest of circulation, blood hadentered a pseudo-lumen. Although this patient fortu-

nately had an uneventful course, blood supply via the

ascending aorta appears to be unreliable in some cases.

Although there are reports describing blood supply

via the ascending aorta with the Seldinger technique,

we believe direct true lumen cannulation of the ascend-

ing aorta to be more reliable.8 This technique is advan-

tageous in that it is simple, it allows accurate blood

supply into the true lumen, and it takes less time to

establish CPB. There is also a view that blood suppliedvia the axillary artery is effective in such cases.

However, this technique must be performed with at

least 2 views. When the operation is carried out by a

small group, it may take longer due to the shortage of 

manpower or obstruction of other views. In this regard,

direct true lumen cannulation, which can be performed

with a single view, may be advantageous. Its shortcom-

ings include temporary hypotension and possible con-

tamination with air at the time of cannula insertion.

However, hypotension lasts only several seconds, and

Table 2.   Operative data according to cannulation technique for antegrade perfusion in 47 patients.

Variable Direct (n¼ 12) Apex (n¼ 20)   p  value Ascending(n¼ 15)   p  value

Time to start of CPB (min) 40 10 51 11   <0.05 48 20   <0.05

AoRþHAR (n)a 7 14 9

CPB time (min) 131

34 223

40  <

0.05 160

34  <

0.05Circulatory arrest (min) 40 9 72 10   <0.05 46 6   <0.05

Aortic crossclamping (min) 111 29 135 30   <0.05 110 27   >0.5

Hypothermia during arrest 27.8C 0.9C 26.3C 2.4C   <0.05 28.1C 1.2C   >0.5

Total arch replacement (n) 5 6 6

CPB time, min 211 11 258 45   <0.05 243 103   <0.05

Circulatory arrest (min) 62 16 90 12   <0.05 76 32   <0.05

Aortic crossclamping (min) 174 13 184 32   <0.05 179 63   >0.5

Hypothermia during arrest 28.4C 1.8C 24.7C 3.9C   <0.05 27.2C 2.0C   >0.5

aAoR  þ  HAR: graft replacement of ascending aorta and hemiarch; Apex: apex cannulation; Ascending: ascending aortic cannulation; CPB: cardiopul-

monary bypass; Direct: direct true lumen cannulation of ascending aorta.

Table 3.  Postoperative data according to cannulation technique

for antegrade perfusion in 47 patients.

Direct Apex Ascending

Variable (n¼ 12) (n¼ 20) (n¼ 15)

Reoperation for bleeding 0 0 0

Deep sternal inflammation 0 0 0

Neurologic disorders

Permanent 1 (8%) 0 1 (7%)

Temporary 0 0 0

Respiratory failure 2 (16%) 5 (25%) 2 (13%)

Ventilation time (h) 37

27 73

11 45

40Hospital mortality (430 days) 1 (8%) 2 (10%) 2 (13%)

Apex: apex cannulation; Ascending: ascending aortic cannulation; Direct:

direct true lumen cannulation of ascending aorta.

286   Asian Cardiovascular & Thoracic Annals 22(3)

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the risk of air contamination is negligible if the patient

is kept in a head-low position and blood is supplied

during insertion of the cannula. If the point of entry

is located distal to the blood supply cannula insertion

point, there is a risk of inserting the cannula into the

false lumen. For this reason, it is essential to avoid

excessively deep insertion of the cannula, to check theperfusion pressure of CPB, and to confirm by epiaortic

ultrasonography after cannula insertion that the tip of 

the blood supply cannula is located within the true

lumen.

Direct true lumen cannulation of the ascending is a

valid means of securing a cerebral blood supply route

during surgery for acute type A aortic dissection in

cases of full-circumference dissection of the tunica

intima of ascending aorta, patients with a narrowed

true lumen, and those with the true lumen located on

the posterior aspect of the aorta. In our experience, this

technique is not inferior to the other currently available

techniques.

Funding

This research received no specific grant from any funding

agency in the public, commerical, or not-for-profit sectors.

Conflict of interest statement

None declared

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