Cardiovascular Journal of Africa: Vol 27 No 3 (May/June 2016)

21 / 102

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 3, May/June 2016 AFRICA 143
Subclavian artery cannulation provides better myocardial
protection in conventional repair of acute type A aortic
dissection: experience from a single medical centre in
Taiwan
Po-Shun Hsu, Jia-Lin Chen, Chien-Sung Tsai, Yi-Ting Tsai, Chih-Yuan Lin, Chung-Yi Lee, Hong-Yan
Ke, Yi-Chang Lin
Abstract
Background: Although many reports have detailed the advan-
tages and disadvantages between femoral and subclavian arte-
rial cannulations for acute aortic dissection type A (AADA),
the confounding factors caused by disease severity and surgical
procedures could not be completely eliminated. We compared
femoral and subclavian artery cannulation and report the
results for reconstruction of only the ascending aorta.
Methods: From January 2003 to December 2010, 51 AADA
cases involving reconstruction of only the ascending aorta
were retrospectively reviewed and categorised on the basis
of femoral (n = 26, 51%) or subclavian (n = 25, 49%) artery
cannulation. Bentall’s procedures, arch reconstruction and
hybrid operations with stent-grafts were all excluded to
avoid confounding factors due to dissection severity. Surgical
results, postoperative mortality, and short- and mid-term
outcomes were compared between the groups.
Results: Subclavian cannulation had a lower incidence of cere-
bral and myocardial injury and lower hospital mortality than
femoral cannulation (8 vs 34%, p = 0.04). Ventilation duration
as well as intensive care unit (ICU) and hospital stay were also
shorter with subclavian cannulation. Risk factors for hospital
mortality included pre-operative respiratory failure (odds
ratio: 12.84), peri-operative cardiopulmonary bypass (CPB)
time > 200 minutes (odds ratio: 13.49), postoperative acidosis
(pH < 7.2, odds ratio: 88.63), and troponin I > 2.0 ng/ml (odds
ratio: 20.08). The overall hospital mortality rate was 21%. The
40 survivors were followed up for three years with survival of
75% at one year and 70% at three years.
Conclusions: Our results show that subclavian cannulation
had a lower incidence of cerebral and myocardial injury
as well as better postoperative recovery and lower hospital
mortality rates for reconstruction of only the ascending aorta.
Keywords: acute aortic dissection, axillary artery cannulation,
femoral artery cannulation, T-graft peripheral cannulation
Submitted 5/3/15, accepted 2/7/15
Cardiovasc J Afr 2016; 27: 143–146
DOI: 10.5830/CVJA-2015-056
Surgical repair of acute aortic dissection type A (AADA) is
always a significant challenge to cardiovascular surgeons. The
key issues involved in this type of procedure include establishing
adequate extracorporeal circulation, repairing the torn intima
and friable aortic wall, and protecting vital organs, especially the
brain, from ischaemia.
In the past two decades, there have been many debates
regarding the use of femoral or axillary artery cannulation.1
Methods used may vary according to the extent of dissection,
which may introduce a major statistical error when comparing
cannulation sites. In this retrospective study, we excluded cases
involving the arch and Bentall’s procedure and identified 51
patients in whom reconstruction of only the ascending aorta was
performed. We analysed short- and mid-term results between
the groups formed on the basis of femoral and subclavian
cannulation. In addition, we predicted risk factors for mortality
based on Kaplan–Meier survival curve results.
Methods
Our study included 51 patients who were diagnosed with
uncomplicated AADA, including DeBakey type I and II, via
computerised tomography (CT) angiography, and had undergone
simple reconstruction of the ascending aorta between 2003
and 2010. Bentall’s or David’s procedure was excluded if the
intimal tear extended into the coronary ostium or aortic valve.
Arch reconstruction was also excluded if any intimal tear was
detected over the greater curve after aortotomy or if dissection
of any one of the arch branches was confirmed on computerised
tomography (CT) angiography.
In total, we excluded three cases of David’s procedure,
seven cases of Bentall’s procedure, and nine cases of arch
reconstruction, as well as two patients who underwent combined
Bentall’s procedure and arch reconstruction. In other words, if
Division of Cardiovascular Surgery, Department of Surgery,
Tri-Service General Hospital, National Defense Medical
Centre, Taipei, Taiwan
Po-Shun Hsu, MD
Chien-Sung Tsai, MD,
Yi-Ting Tsai, MD
Chih-Yuan Lin, MD
Chung-Yi Lee, MD
Hong-Yan Ke, MD
Yi-Chang Lin, MD
Division of Cardiovascular Surgery, Department of Surgery,
Taoyuan Armed Forces General Hospital, National Defense
Medical Centre, Taoyuan, Taiwan
Chien-Suang Tsai, MD
Department of Anesthesia, Tri-Service General Hospital,
National Defense Medical Centre, Taipei, Taiwan
Jia-Lin Chen, MD