Arterial Cannulation and Brain Perfusion Strategies for Acute Type A Dissection in North America.

BACKGROUND

This study was conducted to determine national trends and effect of cannulation and cerebral/brain perfusion (CP) strategies on outcomes during acute type A aortic dissection (ATAAD) surgery.

METHODS

From July 2011 through December 2023, 47,936 ATAAD operations were identified from The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Multivariable logistic regression models for operative mortality and stroke were derived.

RESULTS

Over 12 years, femoral cannulation dropped from 37% to 19%, whereas direct aortic and axillary cannulation increased from 19% to 32% and 26% to 29%, respectively. Retrograde CP was similar (22%), whereas antegrade CP increased (22% to 52%). Repair without CP decreased (52% to 23%). Operative mortality (18%) and stroke (15%) were stable. Compared with axillary with antegrade CP, mortality was similar with aortic cannulation-antegrade CP strategy adjusted for perioperative risk factors but worse when adjusted for hospital volume (adjusted odds ratio [AOR], 1.17; 95% CI, 1.01-1.36). Aortic-retrograde CP strategy was similar (AOR, 1.12; 95% CI, 0.96-1.31). Femoral-antegrade CP (AOR, 1.55; 95% CI, 1.30-1.85) was associated with worse mortality, but not femoral-retrograde CP (AOR, 1.09; 95% CI, 0.93-1.29). Strategy without CP was associated with worse mortality regardless of cannulation. Stroke was higher with femoral cannulation regardless of CP strategy (P < .05), as was aortic cannulation with antegrade CP (AOR, 1.37; 95% CI, 1.18-1.58), but not with retrograde CP (AOR, 1.11; 95% CI, 0.95-1.31).

CONCLUSIONS

Despite positive trends in ATAAD repair, these did not translate into overall improved mortality. To further optimize outcomes, use of CP is preferred over none, and cannulation that provides proximal to distal flow is preferred over femoral. Direct aortic cannulation provides comparable results to axillary, but it seems to demand surgeon expertise and skilled handling of direct antegrade CP.