The use of innominate artery cannulation for antegrade cerebral

Journal Articles

2020

The use of innominate artery cannulation for antegrade cerebral The use of innominate artery cannulation for antegrade cerebral

perfusion in aortic dissection perfusion in aortic dissection

E. C. Payabyab

J. M. Hemli

Zucker School of Medicine at Hofstra/Northwell

A. Mattia

A. Kremers

S. K. Vatsia

Zucker School of Medicine at Hofstra/Northwell

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Recommended Citation Recommended Citation

Payabyab EC, Hemli JM, Mattia A, Kremers A, Vatsia SK, Scheinerman SJ, Mihelis EA, Hartman AR,

Brinster DR. The use of innominate artery cannulation for antegrade cerebral perfusion in aortic

dissection. . 2020 Jan 01; 15(1):Article 7017 [ p.]. Available from:

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Authors Authors

E. C. Payabyab, J. M. Hemli, A. Mattia, A. Kremers, S. K. Vatsia, S. J. Scheinerman, E. A. Mihelis, A. R.

Hartman, and D. R. Brinster

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RES E A R C H A R T I C L E Open Access

The use of innominate artery cannulation

for antegrade cerebral perfusion in aortic

dissection

Eden C. Payabyab

1,2*

, Jonathan M. Hemli

, Allan Mattia

, Alex Kremers

1,5

, Sohrab K. Vatsia

S. Jacob Scheinerman

, Efstathia A. Mihelis

, Alan R. Hartman

and Derek R. Brinster

Abstract

Background: Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been

shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in

acute aortic dissection.

Methods: A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic

reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate

artery cannulation for selective antegrade cerebral perfusion were selected for analysis.

Results: Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections.

Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root

replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending

aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n =

11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean

hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke

occurred in 7 patients (9.3%).

Conclusions: This study is the first comprehensive review of direct innominate artery cannulation through median

sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy

is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for

delivering selective antegrade cerebral perfusion in these cases.

Keywords: Aortic dissection, Aortic arch, Direct innominate cannulation, Cerebral perfusion, Outcomes

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* Correspondence: ecp9004@nyp .org

Meeting Presentation: Presented at the American Association of Thoracic

Surgery Aortic Symposium. New York, New York, April 2018

Division of Cardiac Surgery, Virginia Commonwealth University Health

Systems, Richmond, VA, UK

Department of Cardiothoracic Surgery, New York Presbyterian-Weill Cornell

Medicine, New York, NY, USA

Full list of author information is available at the end of the article

Payabyab et al. Journal of Cardiothoracic Surgery (2020) 15:205

https://doi.org/10.1186/s13019-020-01249-1

Background

Stanford type A dissec tions carry a high mortality with

reports ranging from 17 to 26% [1–4]. Timely operative

intervention improves outcomes with delays increasing

mortality 1–2% every hour in the first 48 h. Repair of the

aortic dissection requires complex circulatory manage-

ment and cerebral protection during circulatory arrest.

Strategies to improve outcomes include hypothermia

alone or in conjunction with antegrade cerebral perfu-

sion (ACP) or retrograde cerebral perfusion (RCP).

Moderate hypothermia with ACP has been shown to be

a safe an d effective strategy from neuroprotection in aor-

tic arch reconstruction including operative interventions

for aortic dissections [5–8].

Several techniques for administering selective ACP

(SACP) have been described including right axillary

artery cannulation with concomitant occlusion of the

base of the innominate artery [9], direct placement of

balloon-tipped catheters into the ostia of the arch vessels

[10], and cannulation of the innominate artery via a

side-graft [11, 12]. Neurologic events with these tech-

niques range from 3.4% in elective aortic arch operations

to 12% in acute Stanford type A dissections. An alterna-

tive technique for SACP, utilizing direct innominate

artery cannulation, has been shown to be safe in elective

arch reconstruction with reported stroke and mortality

rates of 1% [13, 14].

The outcomes of direct innominate artery cannulation

for SACP in acute aortic dissection have yet to be

reported. We sought to evaluate the safety and efficacy

of this technique in acute Stanford type A dissections.

Methods

Patients

We performed a multi-institutional comprehensive

review of all patients who underwent repair of Stanford

type A dissection between 2006 and 2016. Seventy-five

patients had direct cannulation of the innominate artery

for SACP during their dissection repair. The study

protocol was approved by the institutional board reviews

of the Northwell Health System and Virginia Common-

wealth University Health System.

Surgical technique

The dissected ascending aorta is cannulated directly to

initiate cardiopulmonary bypass utilizing transesophageal

echo guidance to place a long percutaneous arterial

cannula placed with Seldinger technique as previously

described [15]. The innominate artery is then cannulated

directly with a 7-French standard-tip DLP aortic root

cannula and connected to the arterial limb of the cardio-

pulmonary bypass circuit utilizing standard 3/8″ tubing,

with a customized 1/4″ branched limb that has a perfu-

sion adapter to attach to the innominate artery cannula.

Figure 1. Once the patient’s core temperature reaches

the desired target (typically moderate hypothermia at

28 °C), the base of the innominate artery is clamped

proximal to the innominate artery cannulation site. The

origin of the left common carotid artery is also isolated

and clamped, keeping the Circle of Willis pressurized

and thereby preventing a ‘steal’ phenomenon. Figure 2.

Cerebral perfusion is measured by an invasive arterial

line situated in the right radial artery, and adjusted

according to arterial pressure and continuous non-invasive

monitoring of cerebral oxygen saturations using near-

infrared spectroscopy.

Results

Preoperative patient demographics are presented in Table 1.

Operative data including details of proximal aortic recon-

struction, concomitant procedures and intraoperative times

Fig. 1 Direct cannulation of innominate artery with 7-French

standard-tip DLP aortic root cannula

Payabyab et al. Journal of Cardiothoracic Surgery (2020) 15:205 Page 2 of 6

are described in Table 2. Perioperative outcomes are listed

in Table 3.

Perioperative stroke occurred in 7 patients (9.3%).

Four patients experienced neurological deficits including

dysphagia and motor dysfunction with complete reso-

lution of symptoms within 30 days. The remaining three

patients (4%), who presented in extremis, unable to asses

neurologic exam and found to have hemopericardium,

had no improvement in neurologic status resulting in

poor prognosis and family withdrawal of care. In the

patients presenting to the operating room with no

neurologic deficits and clinically intact there was 5.3%

postoperative neurological complication rate.

Perioperative mortality was 14.7% (11 patients) which

included 3 patients who experienced a neurological

complication. Of our perioperative mortalitie s, 5 patients

presented in extremis. Amongst the 6 patients present-

ing hemodynamically stable the postoperative mortality

was 8%. (Intraoperative death occurred in three patients,

with one unable to wean from bypass and two experien-

cing uncontrollable hemorrhage. These patients were

hypotensive on presentation, with two requiring CPR

Fig. 2 The origin of the left common carotid artery is also isolated

and clamped, keeping the Circle of Willis pressurized and thereby

preventing a ‘steal’ phenomenon

Table 1 Patient Demographics

Patient Demographics

Variable n (%)

Female gender 28 (37.3)

Age, years (mean ± SD) 58.9 ± 15.8

BMI, kg/m

(mean ± SD) 29.9 ± 9.6

Hypertension 37 (49.3)

History of smoking 35 (46.7)

Dyslipidemia 25 (33.3)

Heart failure 10 (13.3)

Cerebrovascular disease 10 (13.3)

Peripheral vascular disease 8 (10.7)

History of prior MI 8 (10.7)

Chronic lung disease 8 (10.7)

Marfan syndrome 1 (1.3)

SD Standard deviation, MI Myocardial infarction

Table 2 Operative Data

Operative Data

Variable n (%)

Proximal aortic reconstruction

Isolated replacement of ascending aorta 36 (48.0)

Ascending Aorta and arch replacement 4 (5)

Aortic root replacement 35 (46.7)

Composite valve-graft conduit 32 (42.7)

Valve-sparing 3 (4.0)

Total arch replacement 7 (9.3)

Concomitant procedures

Frozen elephant trunk 11 (14.7)

CABG 20 (26.7)

Peripheral arterial bypass 4 (5.3)

Cardiopulmonary bypass time, minutes (mean ± SD) 166.1 ± 71.9

Aortic cross-clamp time, minutes (mean ± SD) 108.1 ± 47.7

Circulatory arrest time, minutes (mean ± SD)* 19.2 ± 13.0

Lowest intraoperative temperature, °C (mean ± SD) 24.8 ± 11.1

CABG Coronary artery bypass grafting, SD Standard deviation

Table 3 Perioperative Outcomes

Perioperative Outcomes

Variable n (%)

Stroke 7 (9.3)

Re-operation for bleeding 6 (8.0)

Perioperative MI 1 (1.3)

Deep sternal wound infection 2 (2.7)

New renal failure requiring dialysis 11 (14.7)

Prolonged intubation 37 (49.3)

Tracheostomy 5 (6.7)

Multi-system organ failure 8 (10.7)

Limb ischemia 4 (5.3)

Postop length of stay, days (median ± SD) 10.0 ± 9.1

30-day mortality 11 (14.7)

MI Myocardial infarction, SD Standard deviation.

Payabyab et al. Journal of Cardiothoracic Surgery (2020) 15:205 Page 3 of 6

and all found to have hemopericardium. A 63-year-old

male who underwent an ascending arch, aortic root

replacement, hemiarch and CABG required ECMO for

ventricular assistance secondary to ventricular fibrilla-

tion. He required a re-exploration on postoperative day

one for bleeding, required a left ventricular repair, and

interventions for ventricular fibrillation. Given the likely

poor outcome the patient’s family withdrew care. A 51-

year-old male that presented with malperfusion and

Type I dissection underwent replacement of ascending

aorta with resuspension of the aortic valve, hemi-arch

replacement, placement of descending thoracic aortic

stent graft and ascending aorta to left femoral artery

bypass. Postoperatively the patient required continued

administration of blood products and vasopressors due

to coagulopathic bleeding and hypotension. The patient

experienced multisystem organ failure leading to death. A

79-year-old female underwent a complex aortic root

replacement, ascending aorta and proximal arch replace-

ment and a 2 vessel CABG who experienced disseminated

intravascular coagulopathy and postoperative liver failure

leading to multiorgan system failure and eventual death.

Discussion

Early mortality in patients undergoing surgical repair of

type A aortic dissection is reported as high as 31%. (3)

Developing an efficient and safe surgical technique to

cannulate and provide cerebral perfusion is essential to

successfully perform a repair of type A aortic dissection

pathology. Several cannulation techniques have been

described for the use of arterial inflow in the surgical

repair of type A aortic dissections, all with potential ben-

efits and drawbacks. Femoral artery cannulation, carries

the potential complication of cerebral embolization and

organ malperfusion. The use of the axillary artery for

arterial inflow via a side-graft or direct cannulation has

the disadvantage of needing a second incision and the

additional time to cannulate the axillary artery [9, 16].

Direct cannulation of the innominate artery for full

cardiopulmonary bypass is an altern ative cannulation

site described [11 , 13, 17]. Preventza et al describe in-

nominate artery cannulation with the use of a side graft

as an alternate technique to peripheral cannulation for

surgical repair, having a low stroke and mortality rate

[12]. An advantage of these techniques in the use of these

sites for SACP during circulatory arrest. The use of central

cannulation has also been shown to be safe in the surgical

repair of type A aortic dissections [15, 18, 19].

Evaluation of the different cannulation strategies by

various groups show similar outcomes. Kamiya et al [20]

reviewed 235 patients who underwent operative inter-

vention for type A aortic dissection. They compared the

patients who underwent cannulation of the ascending

aorta and femoral artery and found no difference in

long-term outcomes between the two groups. Stamou

et al [21 ] compared early postoperative outcomes in 305

patients at multiple institutions who underwent axillary

versus femoral cannulation over ten years. They found

no difference in operative mortality.

The use of antegrade cerebral perfusion (ACP) has

been shown to reduce neurologic morbidity after

hypothermic circulatory arrest in proximal aortic recon-

struction [22, 23]. Several techniques for administering

selective ACP have been described including right axil-

lary cannulation with concomitant occlusion of the base

of the innominate artery, direct placement of balloon tip

catheters into the ostia of the arch vessels under direct

vision after circulatory arrest and cannulation of the in-

nominate artery after circulatory arrest via a side-graft.

Neurologic events with these techniques are reported to

be up 12% in acute type A dissections [9, 10, 24]. Our

use of direct innominate artery cannulation for SACP

(9.3%) are similar. Of the 7 patients, 3 presented in

extremis unable to be evaluated neurologically. In evalu-

ating patients who presented neurologically intact, our

neurologic events (4%) are decreased compared to other

techniques.

An alternate technique for SACP, utilizing direct innom-

inate artery cannulation has been described. Garg et al [25]

describe a technique in which central aortic cannulation for

elective aortic surgery. is performed followed by direct

innominate artery cannulation with a 14F pediatric venous

cannula for SACP after hypothermia. They reported

outcomes of 50 patients who underwent replacement of the

ascending aorta using an open distal anastomosis or hemi-

arch replacement. The operative mortality was 2% with a

stroke rage of 2%. A similar technique for elective aortic

surgery described by Jassar et al [13] utilizes direct cannula-

tion of the innominate artery for SACP. Their technique

includes arterial cannulation of the ascending aorta and use

of a short tipped 9-Fr cardioplegia catheter for direct

innominate cannulation following hypothermia and circula-

tory arrest. Our method is similar apart from their use of a

larger cannula to directly cannulate the innominate artery.

They evaluated 100 elective hemiarch reconstructions with

results that showed a 30-day in-hospital mortality and

stroke rate of 1%.

Conclusions

The use of direct innominate artery cannulation with an

accessory cannula for SACP in elective ascending aortic

repairs is comparable to alternative methods. To our

knowledge the use of this method in acute type A aortic

dissection have yet to be reported. We performed a

multi-institutional review of 75 patients over ten years.

All these patients underwent direct cannulation of the

innominate artery with a 7-French standard-tip DLP

aortic root cannula. Our patient cohort included seven

Payabyab et al. Journal of Cardiothoracic Surgery (2020) 15:205 Page 4 of 6

patients who presented with extension of the dissection

into the innominate artery, which did not preclude the

use of the technique. Our 30-day mortality was 14.7%

and a perioperative stroke rate of 9.3%. These outcomes

compare to those reported in other contemporary series

of acute dissection repair, including IRAD data.

Our study has limitations of being a retrospective and

non-comparative review. The experience is multi-

intuitional but is limited to a single surgeon experience.

Within these limitations, our experience suggests that

direct innominate artery cannulation is a simple, fast,

safe, and effective method of administrating SACP

during hypothermic circulatory arrest for patients with

acute type A dissection.

Abbreviations

SACP: Selective antegrade cerebral perfusion; ACP: Antegrade cerebral

perfusion; RCP: Retrograde cerebral perfusion

Acknowledgements

Not applicable.

Authors’ contributions

ECP: design of the work, acquisition, analysis, interpretation of data and

drafted the work; JMH: contribution to the conception, acquisition, analysis,

interpretation of data; revised work; AM: acquisition, analysis, interpretation

of data; AK: acquisition, analysis, interpretation of data; SKV: analysis,

interpretation of data; JS: contribution to the conception, interpretation of

data; EAM: design of the work, acquisition, analysis, interpretation of data;

ARH: contribution to the conception, interpretation of data; DRB: conception

and design of work, acquisition, analysis, interpretation of data and revision

of wok. The author(s) read and approved the final manuscript.

Funding

No sources of funding to declare.

Availability of data and materials

The datasets used or analyzed during the current study are available from

the corresponding author on reasonable request.

Ethics approval and consent to participate

Institutional board reviews of the Northwell Health System and Virginia

Commonwealth University Health System.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

Division of Cardiac Surgery, Virginia Commonwealth University Health

Systems, Richmond, VA, UK.

Department of Cardiothoracic Surgery, New

York Presbyterian-Weill Cornell Medicine, New York, NY, USA.

Department of

Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health,

New York, NY, USA.

Department of Cardiovascular and Thoracic Surgery,

North Shore University Hospital / Northwell Health, Manhasset, NY, USA.

Rush University, Chicago, IL, USA.

Received: 24 March 2020 Accepted: 21 July 2020

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